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.
Diagnostic uncertainty can lead to misdiagnosis and delayed treatment. This article provides an overview of the literature on diagnosis-related uncertainty, where uncertainty occurs in the diagnostic process and outlines recommendations for managing diagnostic uncertainty.
Newman B, Joseph K, Chauhan A, et al. Health Expect. 2021;24:1905-1923.
Patients and families are essential partners in identifying and preventing safety events. This systematic review characterizes patient engagement along a continuum of engagement that includes consultation (e.g., patients are invited to provide input about a specific safety issue), involvement (e.g., patients are asked about their preferences/concerns and given the opportunity to engage with practitioners about a specific issue), and partnership/leadership (e.g., patients ‘work’ with practitioners to improve the safety of their care, often using tools designed to empower patients to alert practitioners to concerns).
Pinheiro LC, Reshetnyak E, Safford MM, et al. Med Care. 2021;59:901-906.
Prior research has found that racial/ethnic minorities may be at higher risk for adverse patient safety outcomes. This study evaluated racial disparities in self-reported adverse events based on cross-sectional survey data collected as part of a national, prospective cohort evaluating stroke mortality. Findings show that Black participants were significantly more likely to report a preventable adverse event attributable to poor care coordination (e.g., drug-drug interaction, emergency department visitor, or hospitalization) compared to White participants.
Spencer RA, Singh Punia H. Patient Educ Couns. 2021;104:1681-1703.
Communication failures during transitions of care can threaten safe patient care. Although this systematic review identified several tools to support communication between inpatient providers and patients during transitions from hospital to home, the authors did not identify any existing tools to support the post-discharge period in primary care.
Lippke S, Derksen C, Keller FM, et al. Int J Environ Res Public Health. 2021;18:2616.
Communication is an essential component of safe patient care. This review of 71 studies found that communication training interventions in obstetrics can improve communication skills and behavior, particularly when combined with team training. The authors identified a lack of evidence regarding the effect of communication trainings on patient safety outcomes and suggest that future research should assess this relationship. Study findings underscore the need for adequate communication trainings to be provided to all staff and expectant mothers and their partners.
Belasen AT, Hertelendy AJ, Belasen AR, et al. Int J Qual Health Care. 2021;33:mzaa140.
Effective communication between patients and providers has been linked to safer care. This cross-sectional analysis of data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) identified a positive correlation between overall hospital rating and both nurse and doctor communication measures, as well as measures of care transition.
This study used qualitative methods to compare how patients versus front clinicians, administrators and staff conceptualize patient safety in primary care. Findings indicate that work function-based conceptualizations of patient safety (e.g., good communication and providing appropriate, timely care) better reflect the experiences of healthcare personnel and patients rather than domain-based conceptualizations (e.g., diagnosis, care transitions, and medications).
Brommelsiek M, Said T, Gray M, et al. Am J Surg. 2021;221:980-986.
Silence in the operating room (OR) can have implications on surgical team function and patient safety. Through interviews with interprofessional surgical team members, the authors explored the influence of silence on team action in the OR and found that silence in the surgical environment – whether due to team cohesion or individual defiance – has implications for team functions.
Diagnostic error is an ongoing patient safety challenge, and can be exacerbated by the hectic pace of the emergency department (ED). This study assessed the feasibility of the Leveraging Patient’s Experience to Improve Diagnosis (LEAPED) program to measure patient-reported diagnostic error after ED discharge. Across three EDs, patient uptake of the program was high. Findings show that 23% of patients did not receive an explanation of their health problem upon discharge, and one-quarter of those patients did not understand the next steps after leaving the ED.
Handoffs are essential to communicating important information and preventing adverse patient care outcomes. This qualitative study explored how information about ICU patients’ family members is included in handovers. Findings suggest that written documentation about the family is inadequate and poorly structured and there is a need for user-friendly handoff tools that include information on patients’ family members.
Bittman J, Nijjar AP, Tam P, et al. J Patient Saf. 2020;16:e169-e173.
This study found that two early warning scores – the Modified Early Warning Score (MEWS) and the National Early Warning Score (NEWS) – can predict patients at risk of deterioration and who will need to be seen by a physician overnight. The authors conclude that use of such early warning scores may be useful for improving handoffs and resource allocation for overnight care.
Daliri S, Boujarfi S, el Mokaddam A, et al. BMJ Qual Saf. 2021;30:146-156.
This systematic review examined the effects of medication-related interventions on readmissions, medication errors, adverse drug events, medication adherence, and mortality. Meta-analyses indicate that medication-related interventions reduce 30-day readmissions and the positive effect increased with higher intervention intensities (e.g., additional intervention components). Additional research is required to determine the effects on adherence, mortality, and medication errors and adverse drug events.
Sunkara PR, Islam T, Bose A, et al. BMJ Qual Saf. 2020;29:569-575.
This study explored the influence of structured interdisciplinary bedside rounding (SIBR) on readmissions and length of stay. Compared to the control group, the odds of 7-day readmission were lower among patients admitted to a unit with SIBR (odds ratio=0.70); the intervention did not reduce length of stay or 30-day readmissions.
This pilot study evaluated the impact of transitional care pharmacist medication-related interventions in skilled nursing settings on 30-day hospital readmissions. The intervention group received transitional services involving a pharmacist (such as medication reconciliation, coordination with the skill nursing case manager and physician, and patient/caregiver education) and the control group received transitional services without pharmacist involvement. Over the follow-up period, median time to readmission was significantly longer in the intervention group but 30-day readmission rates were non-statistically significantly lower in the intervention compared to control group.
Balsom C, Pittman N, King R, et al. Int J Clin Pharm. 2020:Epub Jun 3.
Polypharmacy is one risk factor for medication errors in older adults. This study describes the implementation of a pharmacist-administered deprescribing program in a long-term care facility in Canada. Over a one-year period, residents were randomized to receive either a deprescribing-focused medication review by a pharmacist or usual care. The intervention resulted in fewer medications taken by residents the intervention group after 6 months. Most deprescribing recommendations reflected a lack of ongoing indication or a dosage that was too high.
Unprofessional behavior can hinder patient safety and create a disruptive work environment. Encompassing both qualitative and quantitative literature, this systematic review explored predictors and triggers of incivility in medical teams (defined as disrespectful behaviors but whose intent to harm is ambiguous). The review identified a wide range of triggers of incivility. Studies generally found that incivility occurs mainly within professional disciplines rather than across disciplines (e.g., physician to nurse) and surgery was the most commonly cited uncivil specialty. Situational and cultural triggers for incivility included excessive workload, communication issues, patient safety concerns, lack or support, and poor leadership.
Härkänen M, Turunen H, Vehviläinen-Julkunen K. J Patient Saf. 2020;16.
This study compared medication errors detected using incident reports, the Global Trigger Tool method, and direct observations of patient records. Incident reports and the Global Trigger Tool more commonly identified medication errors likely to cause harm. Omission errors were commonly identified by all three methods, but identification of other errors varied. For example, incident reports most commonly identified wrong dose and wrong time errors. The contributing factors also varied by method, but in general, communication issues and human factors were the most common contributors.
Wiig S, Hibbert PD, Braithwaite J. Int J Qual Health Care. 2020;32.
The authors discuss how involving families in the investigations of fatal adverse events can improve the investigations by broadening perspectives and providing new information, but can also present challenges due to emotions, trust, and potential conflicts in perspectives between providers and families.
Kim S, Appelbaum NP, Baker N, et al. J Healthc Qual. 2020;42:249-263.
This review summarizes studies of training programs targeting healthcare professionals’ speaking up skills. The authors found that most training programs were limited to a one-time training delivered to a single profession (i.e., limited to doctors or nurses). The majority of programs addressed legitimate power (i.e., social norms such as titles) but few addressed other types of power (e.g., reward or coercive power, personal resources) or the non-verbal (i.e., emotional) skills required in speaking-up behaviors.
Giardina TD, Royse KE, Khanna A, et al. Jt Comm J Qual Patient Saf. 2020;46:282-290.
This study analyzed self-reported adverse events captured on a national online questionnaire to determine the association between patient-reported contributory factors and patient-reported physical, emotional or financial harm. Contributory factors identified in the analysis focused on issues with health care personnel communication, fatigue, or response (e.g., doctor was slow to arrive, nurse was slow to respond to call button). These patient-reported contributory factors increased the likelihood of reporting any type of harm.
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