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.
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
Jeffries M, Keers RN, Phipps DL, et al. PLoS One. 2018;13:e0205419.
Pharmacists enhance medication safety in hospitals and ambulatory settings. The authors interviewed pharmacists about their experience implementing a dashboard that allowed them to identify and provide feedback regarding hazardous medication prescribing in primary care. A WebM&M commentary describes other pharmacy-led efforts to make prescribing safer.
Curran C, Lydon S, Kelly M, et al. J Patient Saf. 2018;14:e9-e18.
Several surveys have been developed to measure safety culture in the ambulatory setting. In this systematic review, researchers assessed 17 distinct safety culture survey tools used in the primary care setting and conclude that the psychometric assessment of many of these instruments is limited.
Verbakel NJ, Langelaan M, Verheij TJM, et al. J Patient Saf. 2016;12:152-8.
Most studies of safety culture have focused on hospitals, but the majority of health care takes place in outpatient care. Safety culture in primary care differs from hospital settings. This systematic review was only able to identify two studies, each with significant methodological shortcomings, that examined how to enhance safety culture in primary care. The authors suggest that more intervention studies of safety culture improvement in primary care are needed.
Rockville, MD; Agency for Healthcare Quality and Research; March 2016.
Patient safety culture surveys uncover insights into organizational culture and practice areas that require improvement. This selective resource list offers materials for ambulatory surgery centers that seek to implement changes in response to survey results.
Berry JC, Davis JT, Bartman T, et al. J Patient Saf. 2020;16:130-136.
A culture of safety is a fundamental component of patient safety. Several validated survey tools are available to measure hospital safety and teamwork climates, including the AHRQ Surveys on Patient Safety Culture and the Safety Attitudes Questionnaire (SAQ). Improvements in SAQ scores have been previously linked to reductions in specific safety outcomes, such as maternal and fetal adverse events in an obstetric ward. This study explored SAQ results and outcomes across all inpatient and outpatient care units in a large academic health system. Beginning in 2009, Nationwide Children's Hospital in Ohio introduced a comprehensive patient safety and high reliability program that included numerous quality improvement activities and extensive training in error prevention for each of their approximately 10,000 employees. Over the course of 4 years, SAQ scores improved while all-hospital harm, serious safety events, and severity-adjusted hospital mortality all decreased significantly. A prior WebM&M interview with J. Bryan Sexton, the primary author of the SAQ instrument, discussed the relationship between culture and safety.
Famolaro T, Yount N, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2015. AHRQ Publication No. 15-0041-EF.
This survey expands AHRQ's patient safety culture work to the community pharmacy setting. Approximately 1600 pharmacy staff from 255 community pharmacies voluntarily completed the survey between 2013 and 2014. The database is meant to allow for comparison and benchmarking of safety cultures across pharmacies. However, the current response rate represents less than 1% of total community pharmacies in the United States, and more than half of respondents were chain drugstores or integrated health systems. Most community pharmacies scored well for patient counseling and communication openness, while staffing, work pressure, and pace represented the biggest areas for potential improvement. A prior AHRQ WebM&M interview with J. Bryan Sexton explored the relationship between culture and patient safety.
Health care–associated infections are a known contributor to adverse events among patients on dialysis. Building on evidence and insights from clinicians, this four-part toolkit includes videos, assessment tools, and slide presentations regarding how to apply principles of teamwork, patient engagement, and safety culture to ensure dialysis centers provide safe care to patients with end-stage renal disease.
Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).
The 115 articles freely available in this latest issue of AHRQ's Advances in Patient Safety represent the state of the art in patient safety. Serving as an update and extension to the prior volume, the articles are grouped into four major content areas—assessment, culture and redesign, performance and tools, and technology and medication safety—and are freely available online through the link below.
Modak I, Sexton B, Lux TR, et al. J Gen Intern Med. 2007;22:1-5.
While several surveys have been developed to measure the culture of safety in inpatient settings, no outpatient-specific resource yet exists. In this study, funded in part by the Agency for Healthcare Research and Quality (AHRQ), the investigators adapted the Safety Attitudes Questionnaire to address safety culture in the outpatient arena. The resulting 62-item questionnaire was pilot tested in an academic multispecialty practice and was found to reliably identify safety issues. The survey is posted online at the authors' Web site.
Ashcroft DM, Morecroft C, Parker D, et al. Qual Saf Health Care. 2005;14:417-21.
Safety culture assessments largely focus on the hospital setting. This study developed a tool to identify, stimulate, and evaluate areas for improvement based on a series of focus groups with 67 community pharmacists in the United Kingdom. Investigators developed a suitable application of the Manchester Patient Safety Assessment Framework using five accepted levels of safety culture maturity. The authors discuss the levels as pathological, reactive, calculative, proactive, and generative in describing an organization's response to incidents. While the authors suggest that their assessment framework requires additional investigation, they believe the tool may serve as an important mechanism for community pharmacists to improve safety culture.
Kralewski JE, Dowd BE, Heaton A, et al. Med care. 2005;43:817-825.
The study, which analyzed prescription drug error claims for 78 group practices, found both direct and indirect relationships between culture, practice structure, and medication errors. The authors believe that better care coordination can improve medication safety in the outpatient environment.
Henriksen K, Battles JB, Marks ES, et al, eds. Rockville, MD: Agency for Healthcare Research and Quality (US); 2005.
With 4 volumes and 140 articles (all of which are freely available through the link below), this expansive collection of literature illustrates the progress made since the 1999 Institute of Medicine’s report, To Err is Human: Building a Safer Health System. The efforts represent a successful collaboration between the Agency for Healthcare Research and Quality and the Department of Defense-Health Affairs in meeting the challenge of improving patient safety knowledge, research, and implementation.
An antenatal room left in disarray causes a charge nurse to search for the missing patient. Investigation reveals that a resident had performed an ultrasound on a nurse friend rather than a true "patient."
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