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.
Wyner D, Wyner F, Brumbaugh D, et al. Pediatrics. 2021;148:e2021053091.
The dismissal of parental concerns is a known contributor to medical errors in children. This story illustrates how poor communication, lack of respect, and anchoring bias contributed to failure in the care of a boy. The authors share actions being taken by the hospital involved in the tragedy to partner with the family to improve diagnosis practices throughout their organization.
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, care standardization,teamwork, unit-based safety initiatives, and...
The COVID-19 pandemic has shown a spotlight on bias, disparities, and inequity in the healthcare system. The author advocates using the same strategies to reduce inequities that were used to improve patient safety: 1) culture, leadership, and governance; 2) learning systems; 3) workforce; and 4) patient engagement.
LaGrone LN, McIntyre LK, Riggle A, et al. J Trauma Acute Care Surg. 2020;89:1046-1053.
The authors examined contributors to error-associated deaths occurring between 1996-2004 and 2005-2014 and identified a shift from deaths occurring during the early phase of care (e.g., failed resuscitation and hemorrhage) to deaths occurring during the recovery phase (e.g., respiratory failure from aspiration). These findings demonstrate that successful implementation of system improvements can resolve process of care issues, but that ongoing evaluation is critical for continuous process improvement.
Lack of communication and interpersonal dynamics can contribute to failure to rescue. This study surveyed 262 surgical staff about perceived safety climate, but the authors did not find an association between organizational safety culture and failure to rescue or inpatient mortality.
Disruptive behavior is a recognized threat to patient safety. This article reviews the scope of the problem, factors leading to disruptive physicians, consequences of disruptive behavior, and strategies for managing disruptive physicians.
ISMP Medication Safety Alert! Acute Care Edition. 2020;25.
Successful development of a just culture centers on understanding different types of flawed human behavior and designing effective organizational responses to these failures. This article compares human error, at-risk behavior, and reckless behavior to suggest systems design changes for patient safety programs to generate opportunities for improvement.
The authors present a nomenclature to describe eight types of diagnostic errors anticipated in the COVID-19 pandemic (classic, anomalous, anchor, secondary, acute collateral, chronic collateral, strain and unintended diagnostic errors) and highlight mitigation strategies to reduce potentially preventable harm, including the use of electronic decision support, communication tactics such as visual aids, and huddles. Organizational strategies (e.g., peer-support, duty hour limits, and forums for transparent communication) and state/federal guidance around testing and monitoring diagnostic performance are also discussed.
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.
Perea-Pérez B, Labajo-González E, Acosta-Gío AE, et al. J Patient Saf. 2020;16.
Based on malpractice claims data in Spain, the authors propose eleven recommendations to mitigate preventable adverse events in dentistry. These recommendations include developing a culture of safety, improving the quality of clinical records, safe prescribing practices, using checklists in oral surgical procedures, and having an action plan for life-threatening emergencies in the dental clinic.
Disruptive behavior is a recognized deterrent to safe communication, sharing of concerns and teamwork. This educational program highlights a study that measured the impact of unprofessional physician behavior on patient care and features Dr. William Cooper and Dr. Gerald Hickson as speakers.
Unprofessional behaviors negatively impact teams and can undermine patient safety. This systematic review examined the influence of bullying on nursing errors across multiple healthcare settings. Fourteen articles were included in the review and four themes were identified: the influence of work environment; individual-level connections between bullying and errors; barriers to teamwork, and; communication impairment. While nurses perceive that bullying influences errors and patient outcomes, the mechanisms are unclear and more research is necessary to determined how bullying impacts nursing practice error.
O’Connell D. J Clin Outcomes Manag. 2019;26(5):213-218.
Disclosure of errors and adverse events is increasingly encouraged in health care. This article reviews disclosure and resolution pathways and discusses barriers to pathway implementation. Ensuring clinicians are equipped with tools to implement effective disclosure and fair resolution benefits both patient safety and clinician emotional well-being.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2019. ISBN: 9780309495509.
Clinician burnout is a known contributor to unsafe care. This report summarizes evidence on the causes and impacts of clinician burnout. The authors share six recommendations for improvement which include redesign of the learning environment, technologies, and support services for clinicians.
Agency for Healthcare Research and Quality. October 30, 2019.
This webinar recording provides information on the updated Hospital Survey on Patient Safety Culture™ (SOPS™) 2.0. The hospital survey was revised and pilot tested after incorporating user feedback. The Hospital SOPS survey, which has been used by hundreds of hospitals in the U.S. and overseas, allows healthcare providers and staff to assess a hospital’s patient safety culture. Speakers at the webinar discussed what’s different and what to expect when transitioning to the revised survey. Access the SOPS Hospital Survey 2.0, including a user’s guide, as well as results from a 2019 Pilot Test of Version 2.0 and frequently asked questions.
Farag A, Lose D, Gedney-Lose A. West J Nurs Res. 2019;41:954-972.
This survey study demonstrated that nurses are more willing to report medication errors if they perceive that feedback on errors occurs and is nonpunitive. These results underscore the need for a strong safety culture to promote error reporting.
Paradiso L, Sweeney N. Nurs Manage. 2019;50:38-45.
This survey study examined the relationship between just culture—a culture of fairness and responsibility, trust, and error reporting—among nurses. Despite convenience sampling and a response rate of just over 10%, researchers did find a correlation between trust and self-reported likelihood of reporting an error. The authors call for adoption of the just culture model to enhance patient safety.
Holden J, Card AJ. J Patient Saf Risk Manag. 2019;24:166-175.
Negative consequences can radiate throughout an organization after a patient harm event. This commentary provides an overview of first victims, second victims, and third victims of medical errors, then elaborates on how patient safety professionals responsible for investigating adverse incidents and designing improvements can experience emotional stress, bullying, and staff turnover. The authors recommend increased support and measurement of the impact of patient safety events on these individuals.
Fatigue, emotional stress, and illness can affect decision-making and lead to misuse of medications. This newsletter article describes the patient safety impacts of drug diversion among health care workers and notes the importance of a culture of constructive reporting to uncover and address this unsafe behavior.
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