The PSNet Collection

MHA and MHA Keystone Center Annual Reports.

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Okemos, MI: Michigan Health & Hospital Association.

This publication annually reports on the successful outcomes of the Michigan Keystone Center collaborative activities. This most current year's achievements include submission of 134 root cause analysis to the state patient safety organization reporting system. Areas of focus for improvement work included obstetrical safety, workplace safety, and COVID-19 and infection control.

The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science.

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Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.

Maternal safety is threatened by systemic biases, care complexities, and diagnostic issues. This issue brief explores the role of diagnostic error in maternal morbidity and mortality, the preventability of common problems such as maternal hemorrhage, and the importance of multidisciplinary efforts to realize improvement. The brief focuses on events occurring during childbirth and up to a week postpartum.

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.

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Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.

Organizational assessments often provide insights that address overarching quality and safety challenges. This extensive inspection report shares findings from inspections of 36 Veterans Health Administration care facilities. Recommendations drawn from the analysis call for improvements in suicide death review, root cause analysis result application, and safety committee action item implementation.

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Maternal Safety

Global Patient Safety Action Plan 2021-2030: Towards Eliminating Avoidable Harm in Health Care.

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Geneva: World Health Organization; 2021. ISBN: 9789240032705.

The World Health Organization has released the Global Action Safety Plan 2021-2030. This plan provides strategic policy and implementation direction for a wide range of clinical and governmental organizations who work with patient safety. The plan has seven strategic objectives – (1) policies to eliminate avoidable harm, (2) high-reliability systems, (3) safety of clinical processes, (4) patient and family engagement, (5) health worker education, skills, and safety, (6) information, research, and risk management, and (7) synergy, partnership, and solidarity

Mirror, Mirror 2021: Reflecting Poorly

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Schneider EC, Shah S, Doty M, et al. New York, NY: The Commonwealth Fund; August 2021.

A cross-national survey of consumers and physicians reveals that, despite its costliness, the United States health care system continues to rank lower than other countries in quality of care performance.

Leadership To Improve Diagnosis: A Call to Action.

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Rosen M, Ali KJ, Buckley BO, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2021. AHRQ Publication No. 20(21)-0040-5-EF.

The mindset on diagnostic error improvement has gone from a focus on individual skills to that of system factors. This issue brief highlights the influence health system executives have on amending the care environment to facilitate the most effective environment for diagnostic accuracy. This is part of a publication series examining diagnostic improvement across health care.

Each Baby Counts.

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Royal College of Obstetricians and Gynaecologists.

This organization highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm. The reporting initiative closed in 2021 after presenting its final report. Investigations in this area will now be undertaken by the Healthcare Safety Investigation Branch in England.

National Healthcare Quality and Disparities Report: Chartbook on Patient Safety.

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Azam I, Gray D, Bonnett D et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2021. AHRQ Publication No. 21-0012.

The National Healthcare Quality and Disparities Reports review analysis specific to tracking patient safety challenges and improvements across ambulatory, home health, hospital, and nursing home environments. The most recent Chartbook documented improvements in approximately half of the patient safety measures tracked. This set of tools includes summaries drawn from the reports for use in presentations to enhance distribution and application of the data.

Textbook of Patient Safety and Clinical Risk Management.

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Donaldson L, Ricciardi W, Sheridan S, Tartaglia R, eds. Springer Nature: Cham Switzerland; 2021. ISBN 9783030594022.

Foundations and practical experiences are both necessary to implement and sustain change. This publication introduces core theories supporting patient safety improvement. It couples these concepts with discussions of how these can be applied in clinical areas to reduce factors that contribute to unsafe care.

Patient Safety Systems Chapter.

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In: 2021 Comprehensive Accreditation Manual for Hospitals. CAMH. Oakbrook Terrace, IL: Joint Commission; January 2021:PS1-PS46.

This chapter provides information about how organizations can re-design existing programs or launch new initiatives working to meet annual National Patient Safety Goal and accreditation standards. The material focuses on the importance of integrating safety and quality work with frontline activities, evaluating progress of interventions, and learning from critical events to guide improvements.

Incidence of Adverse Events in Indian Health Service Hospitals.

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Office of the Inspector General: Washington DC; December 2020. OIG report OEI-06-17-00530.

Challenges beset safe care delivery for indigenous peoples. This report examines factors contributing to adverse events in this patient population. Recommendations for improvement include an emphasis on harm monitoring and incident reporting. A related report examines the lack of application of maternity best practices in the Indian Health Service.

Improving Diagnostic Quality and Safety/Reducing Diagnostic Error: Measurement Considerations. Final Report

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Washington DC; National Quality Forum: October 6, 2020.

With input from a stakeholder committee, the National Quality Forum identified recommendations for the practical application of the Diagnostic Process and Outcomes domain of the 2017 Measurement Framework for measuring and improving diagnostic error and patient safety. The committee developed four ‘use cases’ (missed subtle clinical findings; communication failures; information overload; and dismissed patients) reflecting high priority examples of diagnostic error that can result in patient harm. The report includes comprehensive, broad-scope, actionable, and specific recommendations for implementing quality improvement activities to engage patients, educate clinicians, leverage technology, and support a culture of safety with the goal of reducing diagnostic errors.

A Guide to Patient Safety Improvement: Integrating Knowledge Translation & Quality Improvement Approaches.

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Edmonton, Alberta; Canadian Patient Safety Institute: 2020. ISBN: 9781926541846.

There is a substantive evidence base of practices that can be deployed to improve patient safety. This guide provides direction for teams to translate knowledge that aids in adapting effective tactics and strategies such as assessments to achieve desired and lasting patient harm reduction.

Culture as a Cure: Assessments of Patient Safety Culture in OECD Countries.

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de Bienassisi K, Kristensenii S, Burtscheri M, et al for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 119.

The assessment of patient safety culture is critical for understanding the success of organizational efforts to provide a foundation for improvement work. This report examines tools used in a variety of countries to assess culture and underscores the value that the assessment of culture can bring to understanding problems and implementing sustainable improvements.

The Care We Need

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Washington DC: National Quality Forum; 2020.

This report builds on the legacy of To Err is Human and Crossing the Quality Chasm to outline an approach to improve the US health care system. Five strategic objectives are provided--one of which focuses on safe care. The report outlines a stratum of actions on which to anchor work over the next decade to generate improvements and increase value. The authors recommend activities that enhance areas of focus such as information technology, equity and patient engagement.

National Diabetes Inpatient Audit -- Harms.

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Leeds, UK: Health and Social Care Information Centre.

This annual report identified a significant number of medication errors associated with diabetes care in acute hospitals in England and Wales.

Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups.

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The COVID-19 pandemic has revealed weaknesses in health care systems worldwide that have affected drug distribution, worker safety and health equity. This report provides a stakeholder analysis of societal conditions affecting patients with coronavirus in the United Kingdom. The authors conclude that racism and discrimination must be considered to correct inequities that impact safe care for Black Asian Minority Ethnic (BAME) patients to effectively respond to COVID-19.

Operational Measurement of Diagnostic Safety: State of the Science.

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Singh H, Bradford A, Goeschel C. Rockville, MD: Agency for Healthcare Research and Quality; April 2020. AHRQ Publication No. 20-0040-1-EF.

This issue brief discusses a sociotechnical approach to understanding safe diagnosis and the range of data sources required for the follow-up and tracking of diagnostic information. The publication recommends a strategy to support health care organizations in identifying and beginning to measure diagnostic error to enable learning. This issue brief is the first in a series on diagnostic safety.

Making Healthcare Safer III.

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Holmes A, Long A, Wyant B, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

This newly issued follow up to the seminal AHRQ Making Health Care Safer report (first published in 2001 and updated in 2013 critically examines the evidence supporting 47 separate patient safety practices chosen for the high-impact harms they address. It includes diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events and nursing-sensitive conditions. The report discusses the evidence on cross-cutting safety practices, including safety culture, teamwork and team training, clinical decision support, patient and family engagement, cultural competency, staff education and training, and monitoring, audit and feedback. The report provides recommendations for clinicians and decision-makers on effective patient safety practices.

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