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.
Gallagher TH, Hemmelgarn C, Benjamin EM. BMJ Qual Saf. 2023;32:557-561.
Numerous organizations promote communication with patients and families after harm has occurred due to medical error. This commentary reflects on perceived barriers to patient disclosure and describes the patient and family perspectives and needs following harm. The authors promote the use of Communication and Resolution Programs (CRP) such as the learning community Pathway to Accountability, Compassion, and Transparency (PACT) to advance research, policy, and transparency regarding patient harm.
White AA, King AM, D’Addario AE, et al. JMIR Med Educ. 2022;8:e30988.
Communication with patients and caregivers is important after a diagnostic error. Using a simulated case involving delayed diagnosis of breast cancer, this study compared how crowdsourced laypeople and patient advocates rate physician disclosure communication skills. Findings suggest that patient advocates rate communication skills more stringently than laypeople, but laypeople can correctly identify physicians with high and low communication skills.
Samuels A, Broome ME, McDonald TB, et al. J Patient Saf Risk Manage. 2021;26:251-260.
Healthcare systems have implemented communication-and-resolution programs (CRPs) (aka CANDOR) to encourage early disclosure of adverse events. This evaluation found that CRP training participants demonstrated improvements in self-reported empathy and communication skills.
Mazor KM, Kamineni A, Roblin DW, et al. J Patient Saf. 2021;17:e1278-e1284.
Patient engagement and encouraging speaking up can promote safety. This randomized study found that patients undergoing cancer treatment who were randomized to an active outreach program were significantly more likely to speak up and report healthcare concerns than patients in the control group.
Ottosen MJ, Sedlock E, Aigbe AO, et al. J Patient Saf. 2021;17:e1145-e1151.
This qualitative study explored the long-term impacts experienced by patients and family members involved in medical harm events. Participants described psychological, social/behavioral, and financial impacts and more than half reported ongoing physical impacts.
Loren DL, Lyerly AD, Lipira L, et al. J Patient Saf Risk Manag. 2021;26:200-206.
Effective communication between patients and providers – including after an adverse event – is essential for patient safety. This qualitative study identified unique challenges experienced by parents and providers when communicating about adverse birth outcomes – high expectations, powerful emotions, rapid change and progression, family involvement, multiple patients and providers involved, and litigious environment. The authors outline strategies recommended by parents and providers to address these challenges.
Elwy AR, Maguire EM, McCullough M, et al. Healthc (Amst). 2021;8:100496.
Disclosure of medical errors is supported by both patients and providers. Following the implementation of the Veterans Health Administration’s policy on disclosing medical errors to patients and their families, it was necessary to determine the effects of implementation (or not) of this policy. This article describes the development, implementation, and sustainment of an error disclosure toolkit for use across the VA system.
Fisher KA, Smith KM, Gallagher TH, et al. Jt Comm J Qual Patient Saf. 2020;46:261-269.
This article evaluates the implementation of the We Want to Know program, which encourages hospitalized patients to speak up about breakdowns in care. Over a three-year period at one large, community hospital, the program interviewed over 4,600 patients and identified 822 (17.6%) who experienced a breakdown in care. Of those, 66.5% identified harm associated with the incident and 61.9% had spoken to someone at the hospital about it. Stakeholders (e.g., nurses, nurse managers, physicians, hospital administrators and leadership) found the program reports provided timely, actionable information and allowed for real-time responses and resolutions. Concerns cited by stakeholders included overlap with exiting patient safety reporting efforts, high level of effort and resources required, ensuring adequate responses.
Mello MM, Frakes MD, Blumenkranz E, et al. JAMA. 2020;323:352-366.
This systematic review synthesized evidence from 37 studies to examine the association between malpractice liability risk and healthcare quality and safety. The review found no evidence of association between liability risk and avoidable hospitalizations or readmissions, and limited evidence supporting an association between risk and mortality (5/20 studies) or patient safety indicators or postoperative complications (2/6 studies).
Carson-Stevens A, Campbell S, Bell BG, et al. BMC Fam Pract. 2019;20:134.
Most patient safety research has focused on tertiary care or specialty care settings, but less is known about safety in primary care settings and there is no clear definition of patient safety incidents and harm occurring in these settings. The authors convened a panel of family physicians and used a consensus method to define “avoidable harm” within family practice. Most scenarios found to be avoidable and included in the proposed definition involved failure to adhere to evidence-based practice guidelines, lack of timely intervention, or failure in administrative processes, such as referrals or procedures for following up on results.
Brown SD, Bruno MA, Shyu JY, et al. Radiology. 2019;293:30-35.
This commentary reviews general aspects of the disclosure movement, supportive evidence, and challenges associated with liability concerns. The authors discuss barriers unique to radiology that have hindered acceptance of the practice and highlight how communication-and-resolution programs can support radiologist participation in disclosure conversations.