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.
The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.
Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.
Rockville, MD: Agency for Healthcare Research and Quality; July 2018.
The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Community Pharmacy Survey and accompanying toolkit were developed to collect opinions of community pharmacy staff on the safety culture at their pharmacies.
Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478:1179-1185.
Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.
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, collaborative initiatives, teamwork, and trigger tools.
Few medical humanitarian organizations have patient safety reporting and analysis systems. Interviews with medical and paramedical staff working in international humanitarian organizations expressed high expectations for organizational leadership to establish clear patient safety and medical error management policies.
Delays in diagnosis and treatment during after-hours care pose serious threats to patient safety. This case-control study compared missed acute coronary syndrome (ACS) cases to other cases with chest discomfort occurring during out-of-hours services in primary care. Predictors of missed ACS included the use of cardiovascular medication, non-retrosternal chest pain, and consultation of the supervising general practitioner.
Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021;17:30-35.
Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.
Patients for Patient Safety Canada. Canadian Patient Safety Institute. August 4, 2020.
Patients injured while receiving health care are susceptible to physical, financial and psychological harm. This webinar introduced strategies to rebuild the physical health of these patients and the trust that they and their loved ones have in the system of care.
Ai A, Desai S, Shellman A, et al. Jt Comm J Qual Patient Saf. 2018;44:674-682.
This study examined ambulatory follow-up of test results by aggregating multiple types of data—national surveys on safety culture and patient satisfaction; patient complaints; safety reports; and electronic health record audits of provider response times. Researchers found an association between quicker response time for test results and higher patient satisfaction. They conclude that merging these disparate data sources can uncover new levers to improve patient safety.
Arbaje AI, Hughes A, Werner N, et al. BMJ Qual Saf. 2019;28:111-120.
Patients are at risk for adverse events after they transition from hospital to home. This direct observation and interview study identified significant concerns related to care transitions from hospital to home health care among patients discharged from the hospital. The study team found instances of missing and erroneous information. Information also had to be gleaned from multiple sources, and too much information could cause confusion and interfere with home health care. The authors recommend redesigning the care transition process from hospital to home health care providers in order to promote safety.
This review of the literature explored the concept of diagnostic reasoning as it applies to nursing practice. Common themes included cognitive bias, dual process thinking, diagnostic error, and patient harm. The author suggests that these concepts be covered in nurse practitioner education as a strategy to improve diagnosis.
Fathy CA, Pichert JW, Domenico HJ, et al. JAMA Ophthalmol. 2018;136:61-67.
Patient complaints are associated with increased malpractice risk. This retrospective cohort study of more than 1300 ophthalmologists sought to determine whether ophthalmologist age was linked to likelihood of receiving unsolicited patient complaints. The authors found that unsolicited patient complaints occur less frequently among older ophthalmologists.
Bridgeman PJ, Bridgeman MB, Barone J. Am J Health Syst Pharm. 2018;75:147-152.
Burnout affects the ability of clinicians and trainees to practice safely. This commentary describes work characteristics that contribute to burnout and reviews organizational and educational strategies to reduce professional burnout among pharmacy practitioners and trainees.
Boyle TA, Bishop A, Morrison B, et al. Res Social Adm Pharm. 2016;12:772-83.
High-quality error investigation can pave the way for safety improvement. This survey of community pharmacists found that a blame-free culture promotes learning from error investigation, but work stress impedes safety culture. The authors suggest that working conditions and safety culture should be addressed in order to improve safety in community pharmacies.
Gardner LA. PA-PSRS Patient Saf Advis. 2016;13:58-65.
Insufficient health literacy is a known patient safety hazard. This article reviews incidents submitted to a state reporting initiative where insufficient patient understanding may have played a role in delayed or missed care and describes a program to encourage adoption of teach-back and other strategies to help patients better comprehend their health care instructions. A past PSNet perspective discussed the role of health literacy in patient safety.
Mixon A, Myers AP, Leak CL, et al. Mayo Clin Proc. 2014;89:1042-51.
Postdischarge medication errors occurred in nearly half of patients hospitalized for acute coronary syndromes or congestive heart failure, with errors more likely to occur in patients with limited health literacy or numeracy.
Chui MA, Stone JA. Res Social Adm Pharm. 2014;10:195-203.
This qualitative study used interviews with community pharmacists to characterize the types of latent errors that can contribute to problems with handoffs in care. Since the handoff process was not standardized, pharmacists reported encountering both information overload and a lack of accurate information when giving and receiving handoffs.