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.
Vo J, Gillman A, Mitchell K, et al. Clin J Oncol Nurs. 2021;25:17-24.
Racial and ethnic disparities in healthcare can affect patient safety and contribute to adverse health outcomes. This review outlines the impact of health disparities and treatment decision-making biases (implicit bias, default bias, delay discounting, and availability bias) on cancer-related adverse effects among Black cancer survivors. The authors identify several ways that nurses may help mitigate health disparity-related adverse treatment effects, such as providing culturally appropriate care; assessing patient health literacy and comprehension; educating, empowering, and advocating for patients; and adhering to evidence-based guidelines for monitoring and management of treatment-related adverse events. The authors also discuss the importance of ongoing training on the impact of structural racism, ways to mitigate its effects, and the role of research and implementation to reduce implicit bias.
Zestcott CA, Spece L, McDermott D, et al. J Racial Ethn Health Disparities. 2021;8:230-236.
Implicit bias can contribute to poor decision-making and lead to poor patient outcomes. This qualitative study found that many healthcare providers have negative implicit attitudes about American Indians, such as implicitly stereotyping American Indians as "noncompliant" patients. The effect of these implicit attitudes and stereotypes was moderated by self-reported cultural competency and implicit bias training.
Structural racism affects both population and individual health. This article proposes four key areas in which the medical and public health communities can contribute in order to change policy and social norms: documenting the impact of racism on health; improving the collection and availability of race and ethnicity data; turning the lens to themselves; and, acknowledging that structural racism has been challenged by mass social movements.
Avesar M, Erez A, Essakow J, et al. Diagnosis (Berl). 2021;8:358-367.
Disruptive and rude behavior can hinder teamwork and diminish patient safety. This randomized, simulation-based study including attendings, fellows, and residents explored whether rudeness during handoff affects the likelihood for challenging a diagnostic error. The authors found that rudeness may disproportionally hinder diagnostic performance among less experienced physicians.
O’Donovan R, McAuliffe E. BMC Health Serv Res. 2020;20:810.
Organizational cultures that encourage psychological safety have been shown to increase safe healthcare. The authors used survey, observational, and interview data to explore psychological safety within four healthcare teams in one hospital. While survey results indicated a high level of psychological safety, observations and interviews identified examples of situations resulting in lower levels of psychological safety, such as absence of learning behavior, low levels of support from other team members, and lack of familiarity among team members.
Herd P, Moynihan D. Health Affairs Health Policy Brief. October 2, 2020.
The crossover of health equity concepts to patient safety has emerged as a consideration for improvement. This policy brief examines how administrative burdens can separate patients from the care they need and calls for increased attention to the problem.
This commentary discusses how we can apply lessons learned in patient safety to address clinician burnout. Lessons include (1) focusing on systems-level factors, (2) institutional and leadership commitment to change, (3) using measurement for accountability, and (4) directed leadership to implement successful change.
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