The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Santhosh L, Lyons PG, Rojas JC, et al. BMJ Qual Saf. 2019;28:627-634.
This mixed-methods study combined survey data from resident physicians with a comparison of process maps from three academic medical centers to assess handoffs from intensive care units to medical wards. The vast majority of survey respondents could recall at least one adverse event related to suboptimal handoff communication between these settings, and review of the process maps revealed safety gaps in existing processes.
Chacko KM, Halvorsen AJ, Swenson SL, et al. Am J Med Qual. 2018;33:405-412.
Engaging trainees in quality improvement efforts has been an important area of focus within graduate medical education, but less is known about how health system resources are aligned with these activities. Researchers used survey data to better understand the perceptions of internal medicine residency program directors regarding health system support for and alignment with graduate medical education quality improvement efforts.
Matern LH, Farnan JM, Hirsch KW, et al. Simul Healthc. 2018;13:233-238.
Training resident physicians to use structured handoff tools reduces errors in the care of hospitalized patients. Researchers developed a handoff simulation incorporating the types of noise and distractions that are ubiquitous in hospitals. After training, distracted residents provided the same quality handoff as those able to communicate in a quiet place.
Pincavage A, Dahlstrom M, Prochaska M, et al. Acad Med. 2013;88:795-801.
When resident physicians leave their primary care clinic at graduation, their patients are vulnerable to adverse events. This internal medicine residency program created an enhanced handoff system that improved continuity, increased appropriate test follow-up, and demonstrated a trend toward reduced hospital and emergency department visits after the care transition. A WebM&M commentary highlighted risks that breaches in continuity pose to outpatients.
Wray CM, Chaudhry S, Pincavage A, et al. JAMA. 2016;316:2273-2275.
Research suggests that standardization, dedicated space, and supervision improve resident handoffs, but less is known about how these best practices are implemented. Investigators surveyed residency program directors and found significant variation in the implementation of recommended handoff practices and educational strategies.
Martin SK, Tulla K, Meltzer DO, et al. J Grad Med Educ. 2017;9:706-713.
This survey study examined remote electronic health record use by attending physicians for resident supervision. Nearly all respondents reported accessing the electronic health record remotely. Of these, 92% reported discovering clinically relevant information that the residents had not conveyed to them. The authors conclude that this "backstage" supervision requires further study to identify best practices for safety and education.
Myers JS, Tess A, McKinney K, et al. J Grad Med Educ. 2017;9:9-13.
It is critical to educate trainees about patient safety. In this study, researchers described lessons learned from creating a leadership role that bridges quality and safety activities with graduate medical education in each of their institutions. Key responsibilities included clinical oversight, faculty development, and educational innovation. The authors advocate for further evaluation of this safety and education leadership role to determine its impact on medical education and patient outcomes.
Pincavage A, Donnelly MJ, Young JQ, et al. Jt Comm J Qual Patient Saf. 2017;43:71-79.
Year-end handoffs in residency training settings are a known patient safety risk. This narrative review found that several practices can enhance the safety of year-end transitions, including standardizing written and verbal signout for high-risk patients and enhancing attending-level supervision.
Greysen R, Harrison JD, Kripalani S, et al. BMJ Qual Saf. 2017;26:33-41.
Hospitals with high readmission rates face reductions in Medicare reimbursements. Understanding the patient perspective at the time of readmission may better inform future readmission reduction efforts. Researchers surveyed patients readmitted to the general medicine services within 30 days of discharge across 12 hospitals on multiple aspects of self-care. Although 91% of patients reported understanding of their discharge plan, more than 52% reported difficulty with at least one aspect of self-care after discharge.
Padula W, Gibbons RD, Valuck RJ, et al. Med Care. 2016;54:512-8.
Severe hospital-acquired pressure ulcers are considered a never event, and they result in loss of payment for the hospitalization according to Centers for Medicare and Medicaid Services (CMS) policy. Bundled interventions have shown success at preventing these complications in research studies, but broader data on their effectiveness have been lacking. This study used administrative data to demonstrate that adoption of evidence-based strategies and implementation of the CMS policy was associated with a decrease in the incidence of hospital-acquired pressure ulcers in academic medical centers.
Farnan JM, Gaffney S, Poston JT, et al. BMJ Qual Saf. 2016;25:153-8.
This simulation study challenged medical students to identify patient safety hazards in a hospital room. Students demonstrated a wide range of accuracy in identifying hazards, with fall risk most likely and pressure ulcer risk least likely to be identified. This finding shows the utility of simulation in patient safety education.
Tanksley AL, Wolfson RK, Arora V. JAMA. 2016;315:603-4.
Clinicians often feel pressured to work while sick or fatigued because of cultural and system factors, including fear of failing colleagues or patients. Exploring findings from a previous study on presenteeism, this commentary spotlights the need for health care organizations to discourage clinicians from working while ill which poses risks to patients. The authors recommend strategies and policies to address this problem, including promoting professionalism that conveys physicians must be healthy enough to provide patient care.
Pincavage A, Lee WW, Beiting KJ, et al. J Gen Intern Med. 2013;28:999-1007.
The academic year-end transfer of primary care patients from graduating residents to their successors can pose risks to patients. This survey of patients within an academic primary care practice identifies the concerns patients have with the transfer process and the barriers in care they encounter as a result.
Greenstein EA, Arora V, Staisiunas PG, et al. BMJ Qual Saf. 2013;22:203-9.
Although much research on effective handoffs has emphasized the responsibility of the sender (the clinician transmitting information), this study evaluated the behavior of clinicians receiving handoffs and found that most clinicians did not engage in active listening behaviors that could improve the quality of information transmission.
Discussing how residents continue to work beyond duty hour limits, this commentary advocates for a new model of professionalism to help faculty and trainees view compliance with duty hours as a professional practice behavior.
Conducted before implementation of the 2011 ACGME duty hour limits, this survey found that the majority of internal medicine and surgery program directors believed the new regulations would negatively affect the learning environment and continuity of care, as well as result in increased faculty workload and require changes in clinical services.