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.
Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. The mismatch between individuals' health literacy skills and the complexity of health information and health care tasks involved in managing health has implications on patient safety.
Betsy Lehman Center for Patient Safety. September 29, 2023, 10:00 AM - 12:30 PM (eastern).
Communication and resolution programs are a promising strategy for successful management of relationships and actions after medical error occurrence. This annual hybrid session explores elements of effective discussions after an adverse event through case simulation and dialogue. The site also includes an archive of videos and materials from previous forums.
Department of Health and Human Services, Agency for Healthcare Research and Quality, Department of Defense.
Effective teamwork plays an essential role in providing safe patient care. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was developed inititally in collaboration by the United States Department of Defense and AHRQ in order to support effective communication and teamwork in health care. The 3.0 version of the widely implemented program is organized around 5 key strategies: patient focus, integrated platform, modular course design, active adult learning and emergent team challenges and opportunities. It provides new tools to measure its impact, supports increased emphasis on the role of patients in teams, and includes a new pocket guide. A PSNet WebM&M commentary discussed how improved teamwork and shared decision-making might have prevented a missed diagnosis of sepsis that lead to the death of a patient.
Rockville, MD: Agency for Healthcare Research and Quality; July 2023.
The TeamSTEPPS® program was developed to support effective communication and teamwork in health care. The curriculum offers training for participants to implement TeamSTEPPS® in their organizations. The 3.0 version of the material has an increased focus on patient engagement and a broader range of clinical, administrative and leadership roles. The course includes updated evidence reviews, trainer guidance, measurement tools, a pocket guide quick reference to keyTeamSTEPPS® concepts and tools, and new patient videos.
Cortegiani A, Ippolito M, Lakbar I, et al. Eur J Anaesthesiol. 2023;40:326-333.
A simulation study in 2017 showed anesthesia residents performed worse when sleep-deprived after working a night shift. In this quantitative study of more than 5,000 European anesthesiologists, participants reported that working night shifts reduced their quality of life and put their patients at risk. Few reported institutional support (e.g., training, fatigue monitoring) for night shift workers. Importantly, this study reports on perceived risk to patients, not actual patient risk.
Browne C, Crone L, O'Connor E. J Surg Educ. 2023;80:864-872.
While medical trainees and residents agree that disclosing errors to patients is important, they also perceive barriers to doing so. In this study, surgical trainees described factors influencing their decisions not to disclose errors despite their intention to do so. Even with formal communication trainings throughout the program, participants reported a lack of sufficient education in error disclosure. Workplace culture and role-modelling influenced their own disclosure practices both positively and negatively.
Chang C, Varghese N, Machiorlatti M. Diagnosis (Berl). 2023;10:105-109.
Clerkship directors indicate clinical and diagnostic reasoning education should be included in medical school curricula, but up to half of programs do not offer it. This article describes the development, implementation, and evaluation of a diagnostic reasoning virtual training for pre-clinical medical students. Students reported increased confidence and understanding of diagnostic reasoning.
AHA Team Training. September 7 - November 2, 2023.
The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This online series will prepare participants to guide their organizations through implementation of the TeamSTEPPS program. It is designed for individuals that are new to TeamSTEPPS processes.
Context (e.g., patient characteristics, setting) can influence clinical reasoning and increase the risk for diagnostic errors. This article explores the ways in which individual-, team-, and system-level contextual factors impact reasoning, clinician performance and risk of error. The authors propose a multilevel framework to better understand how contextual factors impact clinical reasoning.
Lee SE, Repsha C, Seo WJ, et al. Nurse Educ Today. 2023;126:105824.
“Horror room” simulations are used to help train medical students to identify patient safety hazards. This systematic review of 16 studies found that “horror room” simulations are more common in Western countries and focus on medication-related or procedure-related incidents. The authors highlight the need for research establishing parameters regarding the ideal size and composition of the team to yield the highest impact on learners.
Kennedy GAL, Pedram S, Sanzone S. Safety Sci. 2023;165:106200.
Simulation training is an important component of medical education. In this study, researchers compared the impact of traditional clinical skills training with or without interactive virtual reality (VR) on human error among medical students performing arterial blood gas collection. Findings indicate that students who participated in VR-based clinical skills training were less likely to commit errors during simulated practical exam compared to students who did not participate in VR-based training.
Chen H-W, Wu J-C, Kang Y-N, et al. Nurse Educ Today. 2023;126:105831.
Patient safety can be improved when all staff feel empowered to speak up about errors. In this systematic review, the authors identified 11 studies on the effectiveness of trainings to increase nurses' assertiveness to report medical errors. Interventions resulted in significant improvement in nurses' speaking up behavior, but not their attitude or confidence after training. Structured content, use of multiple teaching approaches, and adequate training time were critical to significant improvement.
Cognitive biases, such as heuristics, help clinicians make rapid decisions, but these biases can result in errors. This review sought to explore biases in internal medicine, the impact of biases on patient outcomes, and the effect of debiasing strategies. Forty-one biases were studied, and debiasing strategies showed little to no effect on reducing bias.
D’Angelo A-LD, Kapur N, Kelley SR, et al. Surgery. 2023;174:222-228.
Prior research has asked surgeons how they cope with intraoperative errors, but this study asks operating room personnel how they perceive surgeons' coping strategies. Positive response strategies included announcing that an error has occurred and the plan for managing it. Negative responses include the surgeon becoming visibly upset, raising their voice, and blaming others. The authors suggest additional education on positive strategies to cope with errors during medical education and residency.
This commentary co-written by a medical student and a faculty member explores the presence and impact of implicit bias on the clinician team and patients. The piece introduces a four-step framework through which to examine the origins of bias, how its described, its care impact and how to reduce its effect.
Barnett ML, Meara E, Lewinson T, et al. New Engl J Med. 2023;388:1779-1789.
Best practices for treating patients with opioid use disorder (OUD) include prescribing medications to treat OUD (naltrexone, naloxone, or buprenorphine) and limiting prescriptions of high-risk medications (opioid analgesics and benzodiazepines). This study of more than 23,000 patients with an index event related to OUD sought to determine racial and ethnic differences in safe prescribing. White patients were significantly more likely to receive buprenorphine and less likely to receive high-risk medications than Black or Hispanic patients in the 180 days after the index event. This difference persisted over the four-year study period.
Checklists are increasingly used to support clinical and diagnostic reasoning processes. This study examined the impact of a checklist on electrocardiogram interpretation in 42 first-year general practice residents. Findings indicate that the checklist reduced the time to diagnosis but did not affect accuracy or confidence.
Wiegand AA, Sheikh T, Zannath F, et al. BMJ Qual Saf. 2023;Epub May 10.
Sexual and gender minority (SGM) patients may experience poor quality of healthcare due to stigma and discrimination. This qualitative study explored diagnostic challenges and the impact of diagnostic errors among 20 participants identifying as sexual minorities and/or gender minorities. Participants attribute diagnostic error to provider-level and personal challenges and how diagnostic error worsened health outcomes and led to disengagement from healthcare. The authors of this article also summarize patient-proposed solutions to diagnostic error through the use of inclusive language, increasing education and training on SGM topics, and inclusion of more SGM individuals in healthcare.
Royce CS, Morgan HK, Baecher-Lind L, et al. Am J Obstet Gynecol. 2023;228:369-381.
Racism and implicit biases can threaten the safety of care. The authors in this article outline how implicit bias can affect health professional trainees and impact patient care in obstetrics and gynecology, and outlines strategies to address implicit bias through bias awareness and management curricula, ensuring a supportive learning environment, and faculty development.