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The PSNet Collection: All Content

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.

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Displaying 1 - 20 of 69 Results
Edmondson AC. Hoboken, NJ: John Wiley & Sons, Inc.; 2019. ISBN: 9781119477266.
Psychological safety is foundational to sharing ideas, reporting errors, and raising concerns. This book provides a framework for leaders to develop psychological safety in their organization. The author argues that it is imperative to facilitate an environment that enables staff to freely exhibit the candor, comfort, and openness needed to sustain high performance and innovation.
Joint Commission Resources. Oak Brook, IL: Joint Commission; 2017. ISBN: 9781599409474.
This collection of articles and case studies covers how health care organizations are working to establish and sustain a safety culture. The material includes discussions on the role of leadership, professionalism, and high reliability in improving work environments to support safety.
Woods DD, Dekker S, Cook R, Johannesen L. Boca Raton, FL: CRC Press; 2017. ISBN: 9781317175537.
"Human error," the authors of this book argue, is an inherently misleading term.  Drawing on the field of complexity science, the authors contend that viewing error as a definable and measurable entity fails to account for the complex social and organizational dynamics that allow errors to occur. In this viewpoint, approaches to improving patient safety that focus on measuring adverse events and limiting variability are inherently limited, as they only measure practitioners' behaviors and do not account for the organizational characteristics and influences that establish a culture of safety. The book uses insights from high-reliability organizations and the field of human factors engineering to establish a new paradigm for analyzing safety across a variety of industries.
Washington, DC: National Quality Forum. September 19, 2017.
Although diagnostic error is a well-recognized source of preventable patient harm, measuring and mitigating diagnostic error remains challenging. This National Quality Forum report describes the development of a framework to assist with measuring diagnostic quality and safety. The framework outlines 3 domains and 11 subdomains for measuring diagnostic quality and safety as well as 62 prioritized measure concepts. High-priority areas for measure development include timeliness of diagnosis, timely follow-up of test results, communication and handoffs, patient-reported diagnostic errors, and patient experience related to diagnostic care. The committee also identified several cross-cutting themes and makes recommendations for researchers seeking to develop measures to improve diagnostic safety. A PSNet perspective discussed challenges and opportunities regarding diagnostic error.
Dekker S. Boca Baton, FL: CRC Press; 2017.
This revised and reorganized book provides a primer on how human error causes mishaps and often illustrates deeper troubles within a system. Both the old view of human error that places blame on the individual and the new view that identifies most human failures as merely a symptom of systems-level problems are presented. This view of human error has led to the application of root cause analyses and human factors engineering in health care. New chapters discuss the importance of safety culture and provide recommendations on improving the failure investigation process.
Perlo J, Balik B, Swensen S, et al. Cambridge, MA: Institute for Healthcare Improvement; 2017.
Leadership has a responsibility to establish a culture that fosters staff and clinician well-being as a key component of patient safety. This white paper highlights the importance of enabling joy at work, reviews examples of organizations that have tested strategies to improve joy in work, and provides measurement tools to monitor the effect of initiatives over time. A past PSNet interview discussed joy in practice and physician professional satisfaction.
Dekker S. Boca Raton, FL: CRC Press; 2017. ISBN: 9781472475756.
Although early efforts in the patient safety movement focused on shifting the blame for errors from individuals to system-failures, more recently the pendulum has swung slightly back to try and balance a "no blame" culture with appropriate personal accountability. This tension was notably described early on in the context of resident training programs. Dr. Dekker's book addresses the traditional criminalization of mistakes and draws from several high-risk industries to illustrate how a just culture is a more effective strategy to learn from and prevent error. He argues that a just culture in health care is critical to creating a safety culture. The third edition offers new content related to restorative justice and explores the reasons why individuals break rules.

Shekelle PG, Sarkar U, Shojania K, et al. Technical Brief No. 27. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 16-EHC033-EF.

Most patient safety research and initiatives have focused on the hospital environment, despite the fact that much of health care is delivered in outpatient settings. This technical brief explores gaps in the evidence base that hinder understanding of safety concerns and factors unique to ambulatory care. The evidence review supports use of pharmacist interventions to augment medication safety in outpatient settings. The authors also found that electronic health records have mixed effects on ambulatory safety. Key informants interviewed for the brief noted that studies on patient engagement and diagnostic error are lacking.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2016. Report No. OEI-06-14-00110.
The Office of the Inspector General (OIG) has issued a series of reports analyzing the incidence and preventability of adverse events among Medicare beneficiaries receiving care in acute care hospitals and skilled nursing facilities. This report used similar methodology based on trigger tools to determine adverse event incidence among patients in rehabilitation hospitals—post-acute care facilities that provide intensive rehabilitation to patients recovering from hospitalization for an acute illness or injury. The study found that 29% of patients experienced an adverse event during their stay, a proportion nearly identical to rates at acute care hospitals and skilled nursing facilities. Nearly half of the events were considered preventable, with the most common types of events including pressure ulcers, delirium, and medication errors. Nearly one-fourth of patients who had an adverse event required transfer to an acute care hospital for diagnosis or management, leading to a large increase in costs of care. Based on these data, the OIG has recommended that the Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services disseminate information about patient harms in the rehabilitation setting and work to improve safety at rehabilitation hospitals. A previous WebM&M commentary discussed an adverse event at a rehabilitation facility.
Washington, DC: National Quality Forum; February 2016.
Health information technology (IT) has transformed health care and improved patient safety, but it has also led to unintended consequences that increase the risk for patient harm. This comprehensive report from the National Quality Forum aims to define and prioritize measures of health IT–related safety so that issues can be quantified and monitored over time. The report identifies nine priority areas for measurement, ranging from tracking the extent of system interoperability to clinical decision support to patient engagement. For each area, the authors recommend using a previously published framework to examine three domains: data considerations like availability and interoperability; technology–work system interaction, such as usability, training, governance, and safety monitoring; and application of health IT to make care safer. The committee proposes to hold health IT vendors, health care organizations, and clinicians accountable for specific safety metrics for health IT systems. Although these measures require further development and testing, this report lays the foundation for more systematically evaluating the safety gains and concerns associated with widespread health IT implementation.
Vincent C, Amalberti R. New York, NY: SpringerOpen; 2016
Written by two leaders in the patient safety field, Charles Vincent and Rene Amalberti, this book is available for free download on an open access platform. In the preface, the authors say the title reflects the fact that most current safety initiatives are focused on optimizing clinical processes or system improvements, which may succeed in a reasonably controlled environment. However, they sought to show how methods should be aimed at managing risks in the real, complex conditions of health care. The overall approach is oriented around examining safety from the patient's perspective and establishing patient safety as "the management of risk over time." There are separate chapters dedicated to safety strategies in hospitals, home care, and primary care. A prior PSNet interview with Charles Vincent discussed his career as one of the founders of the patient safety movement.
Rockville, MD: Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No.16-0006-EF.
Hospital-acquired conditions (HACs), some of which are never events, have been an important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading to significant efforts to prevent these conditions. This update to a prior report from AHRQ details and confirms the declining rates in HACs between 2010 and 2013. The analysis indicated that hospitalized patients experienced 1.3 million fewer HACs over the 3 years (2011–2013) than if the HAC rate had remained at the 2010 level. Consequently, the report estimates a $12 billion savings in health care costs and 50,000 fewer hospital patient deaths. These improvements coincided with nationwide efforts to reduce adverse events, such as the Partnership for Patients initiative and Medicare payment reform. The remaining burden of HACs suggests continued investment in this patient safety problem is needed.
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; 2015. ISBN: 9780309377690.
The National Academy of Medicine (formerly the Institute of Medicine) launched the patient safety movement with the publication of its report To Err Is Human. The group has now released a report about diagnosis, which they describe as a blind spot in health care. Available evidence suggests that most Americans will experience a missed or delayed diagnosis in their lifetime. The committee made several recommendations to improve diagnosis, including promoting teamwork among interdisciplinary health care teams, enhancing patient engagement in the diagnostic process, implementing large-scale error reporting systems with feedback and corrective action, and improving health information technology (as recommended in prior reports). Longer-term recommendations include establishing a work system and safety culture that foster timely and accurate diagnosis, improving the medical liability system to foster learning from missed or delayed diagnoses, reforming the payment system to support better diagnosis, and increasing funding for research in diagnostic safety. The report emphasizes the need for much more effort, and far more resources, at the practice, policy, and research levels to address this pressing safety problem.
Wachter R. New York, NY: McGraw-Hill; 2015. ISBN: 9780071849463.
Over the past few years, driven by $30 billion of federal incentives to doctors and hospitals, the adoption rate for electronic health records has dramatically increased, from approximately 10% in 2008 to 70% today. In essence, health care has switched from being a primarily analog to a primarily digital industry. While evidence suggests that the digitization of health care is having a positive effect on safety and quality, many challenges and unanticipated consequences have emerged. Written by a national leader in patient safety, this book chronicles some of these, including physician dissatisfaction, changing relationships among providers and between providers and patients, new kinds of medical mistakes, and problems with clinician work flow. It also highlights some of the opportunities arising from increasingly engaged patients and the entry of Silicon Valley into the health care market. Ultimately, it paints a hopeful picture of where health care information technology may take us, making the case that this positive future state will depend on both the evolution of the software and on changes in culture, training, and the organization of the work.
Weick KE, Sutcliffe KM. San Francisco, CA: Jossey-Bass; 2015. ISBN-13: 9781118862414.
According to Weick and Sutcliffe, high-reliability organizations operate under challenging conditions yet experience fewer problems than would be anticipated as they have developed ways of "managing the unexpected" better than most organizations. The authors, professors at the University of Michigan School of Business, use both case studies and theory-based analysis to explain the methods that result in organizational mindfulness, and, through it, a more robust culture of safety. This third edition of their classic text provides individual chapters on each of the five elements of high reliability and pays increased attention to the roles of interaction, sensemaking, and language in achieving more reliable performance under risky conditions.
Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 15-0011-EF.
This report from the Agency for Healthcare Research and Quality provides estimates on hospital-acquired conditions (HACs)—including never events and health care–associated infections—for hospitals in the United States from 2010 to 2013. These adverse events continue to decline steadily, with an estimated 9% decrease in most recent year over year comparison. In 2013, there were 121 HACs for every 1000 hospital admissions. These improvements resulted in significant cost-savings and reduced morbidity and mortality rates. The authors attribute this change to CMS payment reform and to the Partnership for Patients initiative. Although uncertainty about the cause of these improvements remains, the lower HAC rate clearly demonstrates that efforts to reduce patient safety problems in hospitalized patients are yielding results. The substantial remaining burden of HACs argues for more investment in patient safety in hospital settings.
Hollnagel E. Aldershot, Hampshire, England: Ashgate; 2014. ISBN: 9781472423085.
Historically, the approach to patient safety has been more reactive rather than proactive, involving a response to adverse events and near misses after they occur. This book covers two perspectives of safety: Safety I, a reactive approach that emphasizes reducing adverse outcomes and Safety II, a proactive approach that focuses on ensuring actions go as planned. The author discusses how each approach has been applied in health care and other high-risk industries. A PSNet perspective explored what health care can learn from aviation, another high-risk industry.
Shekelle PG, Wachter RM, Pronovost PJ, et al.; 2013:Evid Rep Technol Assess (Full Rep).(211):1-945.
The seminal AHRQ Making Health Care Safer report, issued in 2001, used evidence-based medicine principles to identify key patient safety practices (PSPs). Although its recommendations were somewhat controversial, the report galvanized patient safety efforts at hospitals nationwide and provided a stimulus for further rigorous research on PSPs. In doing so, the report laid the foundation for the most prominent successes of the safety field. This newly issued follow-up report combines traditional systematic review methodology with the judgments of key stakeholders and technical experts in the field. The authors critically examine the evidence supporting 41 separate PSPs and ultimately arrive at a list of 10 strongly encouraged practices. These practices, if implemented, should result in reduced harm from a wide range of safety threats, including health care–associated infections, medication errors, and pressure ulcers. The report also examines how cost, implementation, and contextual considerations may affect the real-world effectiveness of PSPs, details how foundational concepts such as human factors engineering should be incorporated into safety efforts, and provides a blueprint for future research in patient safety. Formal systematic reviews of 10 key PSPs are also being published simultaneously in a special supplement to the Annals of Internal Medicine.
Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Committee on the Learning Health Care System in America, Institute of Medicine. Washington, DC: National Academies Press; 2012. ISBN: 9780309260732.
This Institute of Medicine (IOM) report presents evidence of poor quality care and significant waste (to the tune of an estimated $750 billion per year) in the American health care system. It emphasizes the importance of continuous learning—not only from high performing health care systems but also from industries such as manufacturing, banking, and aviation—and highlights the role of mobile technologies and electronic health records in continuously improving health care.
Wachter RM, Gupta K. New York, NY: McGraw-Hill Professional; 2017. ISBN: 9781259860249.
The third edition of this widely read textbook, written by national leaders in patient safety, provides an in-depth introduction to the field. The new edition uses case studies to discuss the history of the patient safety movement, the epidemiology of safety hazards, specific error types, and strategies to improve safety in clinical microenvironments and at the organizational level. Substantial new content has been added to highlight emerging areas of the field, such as safety culture, policy and regulatory initiatives to improve safety, and diagnostic errors.