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.
Strategies to reduce clinician burnout related to adverse events are critically needed. Physicians in the United States were surveyed on their experiences with adverse events to identify facilitators and barriers to reducing burnout. A common facilitator was peer support, and barriers included shame and a punitive work environment.
Patients and families impacted by preventable adverse events frequently share their stories when advocating for safety improvements. The author of this commentary urges healthcare, patient safety, and quality improvement professionals to listen to patient safety stories, not just as technical information, but as behavioral challenges.
Debriefing is an important strategy for learning about and making improvements in individual, team, and system performance. It is one of the central learning tools in simulation training and is also recommended after significant clinical events.
Finney RE, Czinski S, Fjerstad K, et al. J Pediatr Nurs. 2021;61:312-317.
The term “second victim” refers to a healthcare professional who was involved in a medical error and subsequently experiences psychological distress. An American children’s hospital implemented a peer support program for “second victims” in 2019. Healthcare providers were surveyed before and after implementation of the program with results showing the highest ranked option for support following a traumatic clinical event is peer support. Most respondents indicated they were likely to use the program if a future clinical event were to occur.
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, collaborative initiatives, teamwork, and trigger tools.
Kruper A, Domeyer-Klenske A, Treat R, et al. J Surg Educ. 2021;78:1024-1034.
Physicians commonly experience adverse psychological outcomes after being involved in an adverse event. This mixed-methods study of health care providers in the Department of Obstetrics & Gynecology at one large academic hospital found that three-quarters of providers experienced symptoms of traumatic stress after involvement in an adverse event. Respondents reporting anxiety were more likely to be interested in peer-to-peer support programs, whereas those reporting symptoms of guilt preferred debriefing sessions.
Few medical humanitarian organizations have patient safety reporting and analysis systems. Interviews with medical and paramedical staff working in international humanitarian organizations expressed high expectations for organizational leadership to establish clear patient safety and medical error management policies.
Street RL, Petrocelli JV, Amroze A, et al. J Patient Exp. 2020;7:1247-1254.
Patient and family engagement play a critical role in patient safety. This study found that patient and family members perceived that information inadequacy, not listening, and dismissive behavior contributed to communication breakdowns that led to medical errors or close calls. These findings underline the critical role of patient and family engagement to prevent errors and improve care delivery.
Kandasamy S, Vanstone M, Colvin E, et al. J Eval Clin Pract. 2021;27:236-245.
Physicians often experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. Based on in-depth interviews with emergency, internal, and family medicine physicians, this qualitative study explores how physicians experience and learn from preventable medical errors. In addition to exploring themes around the physician’s emotional growth and professional development, the authors discuss the value of sharing and learning from these experiences for colleagues and trainees.
ISMP Medication Safety Alert! Acute care edition. December 3, 2020;25(24).
Infusion misadministration is not always immediately evident. This story illustrates the problem of underdosing during infusions and suggests that unclear policies and lack of problem awareness contribute to the persistence of the mistake. The piece recommends education, use of data, and storytelling as tactics to reduce underdosing.
Khoong EC, Fontil V, Rivadeneira NA, et al. J Am Med Inform Assoc. 2020;28:632-637.
Diagnostic over- and under-confidence in primary care can result in misdiagnosis, impacting millions of patients every year. This intervention study evaluated the effect of peer input on diagnostic confidence on cases with diagnostic uncertainty. In cases with high diagnostic uncertainly, peer input increased provider confidence.
Loving VA, Valencia EM, Patel B, et al. J Breast Imag. 2020.
This article defines eight types of cognitive biases encountered in breast radiology. It proposes individual- and organizational-level approaches to recognizing and mitigating the effects of these biases.
Wu AW, Connors C, Everly GS. Ann Intern Med. 2020;172:822-823.
To address the negative psychological impacts faced by healthcare workers during the COVID-19 crisis, the authors of this commentary recommend three strategic principles for healthcare institutions responding to the pandemic:
Encourage leadership to focus on resilience
Ensure that crisis communication provides both information and empowerment
Create a continuum of staff support within the organization to address a surge in mental health concerns among healthcare workers.
El Hechi MW, Bohnen JD, Westfal M, et al. J Am Coll Surg. 2019;230:926-933.
This paper describes the implementation of a "second victim" peer-support program in the surgery department at a tertiary care center. The program trained surgical attendings and trainees to provide peer-support for other surgeons involved in major adverse events. After one-year follow-up, 81% of affected surgeons elected to receive peer support. The majority (81%) felt the program had a positive impact on safety culture by providing a confidential, safe, and timely intervention for so-called "second victims". A 2011 Perspective on Safety with Dr. Albert Wu discussed ways that organizations can support "second victims."
Diagnostic errors occur due to a variety of factors. This magazine article reports on the persistent misdiagnosis and ineffective treatment of Lyme disease, including how lack of a standardized test for the disease and bias affect diagnosis and treatment of this condition.
Implicit biases can affect communication, diagnosis, and treatment decisions. This news article reports the experience of a neurologist and the biases that negatively influenced her health care, such as lack of respect for women presenting with functional symptoms and premature closure.
Heavey E, Waring J, De Brún A, et al. J Health Soc Behav. 2019;60:188-203.
Engaging patients effectively to promote safety is considered a best practice and is endorsed by organizations such as The Joint Commission. Yet, how patients perceive the responsibility for achieving safety remains poorly understood. Investigators conducted semistructured interviews with 28 patients who were discharged from the hospital to better understand how they attribute responsibility for their safety in the health care setting. Direct responses revealed that patients consider health care professionals as being primarily responsible for patient safety but that patients also perceive themselves as playing a part. Narrative responses illustrated why professionals or patients might be responsible and in what context or situation one group might bear more responsibility than another. A past Annual Perspective discussed patient engagement in safety.
The Beers criteria serve as a standard guidance to inform prescribing decisions in older patients to protect against adverse drug reactions. Written by a registered pharmacist, this commentary relates insights regarding how use of the Beers criteria could have prevented a misdiagnosis in her elderly mother. The author highlights the responsibilities of pharmacists and prescribers to use the list as appropriate to ensure patient safety.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
Beet C, Benoit D, Bion J. Intensive Care Med. 2019;45:505-507.
This commentary discusses current challenges to safety in critical care, such as underperforming decision support, poor organizational learning, and clinician burnout. The authors envision safety improvements due to innovations in processes like wearable monitoring technology that enables rapid response activation, workflow-embedded reflective learning, and patient–clinician collaboration.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.