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.
Müller M, Jürgens J, Redaèlli M, et al. BMJ Open. 2018;8:e022202.
Standardized handoff tools are increasingly implemented to improve communication between health care providers. Although this systematic review identified several studies supporting the use of SBAR as a communication tool to improve patient safety, the authors suggest the evidence is moderate and that further research is needed.
Callen JL, Westbrook JI, Georgiou A, et al. J Gen Intern Med. 2011;27:1334-1348.
Following up test results in a timely fashion is a recognized patient safety problem in primary care, and inadequate follow-up systems are a source of frustration for outpatient clinicians and a relatively common source of malpractice claims. This systematic review found evidence that failure to act on abnormal radiology or laboratory results is common and clearly linked to missed or delayed diagnoses. The review also found wide variation in processes for handling test results across studies. Electronic health records (EHRs) did appear to improve test follow-up rates, although a substantial proportion of abnormal results were not followed up even with EHRs. The authors advocate for more standardized processes for informing patients of abnormal results, and recent guidelines have been published for organizational policies to improve test result communication.
The Partnership for Patients has set a goal of reducing preventable hospital readmissions 20% by the year 2013. This goal was achieved by the landmark care transitions study. However, since that study was conducted in an integrated health care system, concerns linger about the generalizability of the intervention to other settings. This study, funded by the Centers for Medicare and Medicaid Services, sought to evaluate the real world effectiveness of the care transitions intervention at six hospitals in a non-integrated health care system. Despite logistical challenges, the intervention successfully reduced readmissions by 36% in patients who received it compared with patients who did not receive any component of the intervention. As hospitals continue to investigate ways of preventing readmissions and reducing adverse events after discharge, this study provides reinforcement for comprehensive interventions that attempt to bridge the gap between inpatient and outpatient care.
Rivera-Rodriguez AJ, Karsh B-T. Qual Saf Health Care. 2010;19:304-312.
The majority of individual errors are due to failure to perform automatic or reflexive actions. A major risk factor for these "slips" is being interrupted or distracted while performing a task. This review examined the literature on the incidence, risk factors, and effects of interruptions in several clinical settings, ranging from outpatient clinics to the operating room. Although distractions are common and may be associated with increased risk for error, particularly if they occur during medication administration or signout, the authors point out that many interruptions may be necessary to communicate urgent clinical information. They argue for complexity theory–based research to delineate the harmful and beneficial aspects of interruptions, rather than for interventions that seek to simply eliminate interruptions. Checklists have been widely adopted as a means of preventing errors of omission, which may be precipitated by interruptions.
Singh H, Thomas EJ, Mani S, et al. Arch Intern Med. 2009;169:1578-1586.
Inadequate follow-up of diagnostic testing is a known safety issue in both hospital and ambulatory settings. Adoption of information technology approaches serves as a logical solution if designed to effectively notify providers of pending or necessary follow-up actions. This study used tracking software to determine if an electronic alert for abnormal imaging results was acknowledged and acted upon in a Veterans Affairs ambulatory setting. Investigators discovered that their seemingly fail-proof system, which included dual-alert communications, still led to persistent problems with missed test results. They also found that the dual-alert communication system was unexpectedly associated with a lack of timely follow-up. The authors advocate for greater multidisciplinary approaches to address these breakdowns.
van Walraven C, Taljaard M, Bell CM, et al. CMAJ. 2008;179:1013-8.
Significant attention to gaps in the continuity of care has led to past research focused on hospital transitions and medication management systems in the ambulatory setting. This study tracked information exchange between outpatient providers caring for the same patient following hospital discharge. Remarkably, they discovered that information from the previous visit was available at a subsequent visit only 22% of the time. Factors associated with information being available included care by a family physician and whether that physician was treating the patient prior to hospitalization. The findings raise ongoing concerns about poor communication and highlight the need for systems to foster more effective clinical information exchange between providers. A past AHRQ WebM&M perspective discussed care transitions associated with hospital discharge.
Loren DJ, Klein EJ, Garbutt J, et al. Arch Pediatr Adolesc Med. 2008;162:922-927.
Studies of medical error disclosure have demonstrated that, while physicians support disclosure of errors in theory, most "choose their words carefully" in practice and fail to disclose important elements of the error. In this study, pediatricians were presented with error scenarios and asked to describe what they would disclose to the child's parents. Overall, a minority of physicians would fully disclose the error, and most would not offer an explicit apology. An accompanying editorial discusses barriers to disclosing errors and strategies (including communication training) that should be implemented to improve this aspect of patient–physician communication.
Kripalani S, LeFevre F, Phillips CO, et al. JAMA. 2007;297:831-841.
Patients discharged from the hospital experience an unacceptably high rate of medical errors. Prior research suggests that suboptimal communication between hospital physicians and outpatient physicians could contribute to these problems. This study systematically reviewed the literature to determine the frequency of communication problems between physicians at hospital discharge and to identify interventions that ameliorated this problem. The investigators found that direct communication occurred rarely, and the primary means of communication (the dictated discharge summary) generally was not available in a timely fashion and often contained inadequate information for proper follow-up care. Based on this review, the authors provide suggestions for standardizing information transfer at discharge and improving the timeliness of communication.
Gandhi TK, Kachalia A, Thomas EJ, et al. Ann Intern Med. 2006;145:488-496.
Medical errors in the outpatient setting have remained a relatively understudied aspect of patient safety. This study analyzed data from malpractice claims at four liability insurers, similar to companion studies of errors in surgical and emergency department patients, to determine the frequency and causes of missed and delayed diagnoses. Diagnostic errors resulting in patient harm occurred in 181 cases, chiefly consisting of missed or delayed diagnoses of cancer. Failure to reach a timely diagnosis was generally due to multiple process breakdowns, including failure to order an appropriate diagnostic test and inadequate follow-up planning, many of which could be ascribed to physician cognitive errors. As with prior studies using chart review, reviewer's agreement on whether an error occurred was only moderate. The authors note that due to the complexity of contributing factors to outpatient errors, simple solutions are unlikely. An accompanying editorial, available via the link below, considers the differences in the nature of errors and approaches to solving them between the inpatient and outpatient settings and calls for greater attention to tackling outpatient safety issues.
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