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.
Southwick FS, Cranley NM, Hallisy JA. BMJ Qual Saf. 2015;24:620-9.
This study analyzed data from an internet-based reporting system that enabled patients and families to describe adverse events. Respondents reported missed and delayed diagnoses, treatment errors, procedural complications, health care–associated infections, and adverse drug events. Most participants did not experience prompt error disclosure but instead faced a denial of responsibility and secretive behavior, which they related to subsequent mistrust. To prevent adverse events, patients and family members suggested using systems approaches (such as universal handwashing and other infection control measures), improving care transitions between providers, ensuring supervision of trainees, and partnering with patients and families for shared decision-making. These findings underscore the importance of error disclosure, effective communication, and allowing patients to report adverse events in order to enhance safety.
Advance care planning (ACP) has become an increasingly utilized process for exploring and communicating patients' preferences for end-of-life care. This multicenter audit of ACP practices across 12 hospitals in Canada found that even when patients and families have completed ACP, inpatient health care providers are not discussing these preferences during hospitalization nor are they documenting these decisions in the medical record. When there was chart documentation, it did not match the patients' expressed wishes more than two-thirds of the time. The majority of audited cases found that patients were prescribed more aggressive care than they would have preferred. An accompanying editorial argues that these types of "silent misdiagnoses" should be considered medical errors, noting that discussions about code status and ACP are "every bit as important to patient safety as a central line placement or a surgical procedure." A previous AHRQ WebM&M commentary discussed ACP and other tools for expressing end-of-life preferences.
Aiken LH, Sermeus W, Van den Heede K, et al. BMJ. 2012;344:e1717.
Seminal studies in the United States have shown strong associations between nurses' working conditions and patient safety, with high patient-to-nurse ratios and greater patient turnover being linked to increased mortality. This multinational survey of nurses and patients found that improved nurse work environments and reduced patient-to-nurse ratios were linked to better perceptions of quality and patient satisfaction. Moderately strong correlations were found between patient satisfaction and nursing reports of care quality, although there were wide variations in both measures across different countries. This study lends additional support to the view that improving the work environment for nurses can strengthen patient safety.
Delbanco T, Bell SK. N Engl J Med. 2007;357:1682-3.
Disclosure of medical errors remains an important and challenging practice, with a past report providing thoughtful guidance on how to respond. This commentary addresses the humanistic aspect of what patients, families, and clinicians go through in trying to bring closure or forgiveness to the experience. Drawing from interviews highlighted in a documentary film, the authors share a number of specific themes not frequently addressed. These include feelings of concern by patients about the potential for further harm to occur, feelings of isolation by patients from their clinicians when they need them the most, and feelings of guilt by family members that often exceed those of providers. An AHRQ WebM&M commentary, perspective, and interview also discuss multiple facets of error disclosure.
Prior studies have documented the safety problems that befall patients with complex illnesses at the time of transition from one setting of care to another. In this trial conducted in an integrated delivery system, patients were randomized to receive usual care or the care transitions intervention at the time of hospital discharge. Intervention patients received a personal health record and a "transition coach," who assisted with continuity of care across settings, arranged home visits after discharge, and helped train patients and caregivers in self-care methods. The foci of the intervention were on ensuring accurate medication usage and appropriate follow-up care. The intervention successfully reduced the likelihood of hospital readmission for 3 months after discharge and appeared to be cost effective.
Part of a series in JAMA entitled Clinical Crossroads, this case study discusses the unfortunate events surrounding a 38-year-old woman’s presentation to a labor and delivery unit. The case details a seemingly routine full-term pregnancy that rapidly evolved into a course of complications, ultimately leading to a fetal death, a hysterectomy, and a prolonged hospital course. The discussion shares the experience through the eyes of the patient, her husband, and the primary obstetrician. Further exploration of the case identified several specific factors and broader systems issues that contributed to the events. The author shares how this particular institution responded with overarching changes, including a greater emphasis on teamwork, communication, and appropriate staffing of labor and delivery units to promote safety.
Delbanco T, Berwick DM, Boufford JI, et al. Health Expect. 2001;4:144-50.
This viewpoint presents a summary of recommendations from the 1998 Salzburg Seminar entitled “Through the Patient’s Eyes.” The purpose of this seminar series is to offer a neutral forum for discussing beliefs on a variety of topics. The 5-day seminar was attended by 64 individuals from 29 different countries with a mission to create a health care system for a mythical republic called PeoplePower. The premise builds on a principle of “nothing about me without me,” as teams of health professionals, patient advocates, artists, reporters, and social scientists established a conceptual model. The authors share the participants’ visions of an ideal clinician-patient relationship and the role hospitals, national and local governmental agencies, and communities play in supporting such a model. Although they conclude that their health care system remains detached from financial, historical, and societal restraints, the principles serve as reminders that health programs must draw closer together patients and those who care for them.
This detailed review summarizes existing evidence on how people adapt to threatening events by blaming others. Discussion includes a synthesis of past work and explanations for findings from both the psychoanalytic perspective and the social psychology literature. Based on their assessment that these explanations fall short, the authors present a different model that focuses on factors influencing the incidence of blaming others and the consequences of doing so. Their model argues for a relationship between situational factors and personal characteristics, with interpersonal and intrapersonal mediators playing a role, which ultimately leads to adaptation and blame of others. They include a discussion of limitations in their proposed model as well as recommendations for future study.
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