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.
King S. New York, NY: Atlantic Monthly Press; 2009. ISBN: 9780802119209.
This memoir shares the story of Sorrel King's crusade to make medical care safer. Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months because of medical errors during a hospitalization at Johns Hopkins Hospital. She has subsequently become one of the nation's foremost patient advocates for safety, forming an influential foundation (the Josie King Foundation) and partnering with Johns Hopkins to promote the field of patient safety around the world.
This article by bestselling author and surgeon Atul Gawande illustrates the complexity of intensive care and profiles Peter Pronovost, the Johns Hopkins intensivist and safety leader whose efforts to standardize safety practices led to remarkable reductions in ICU harm in Michigan hospitals. It goes on to a broader discussion of how checklists and decision support have reduced errors and transformed safety in critical care. Gawande also reflects on how implementation of standardized approaches often conflicts with the traditional physician culture, which prizes individual expertise over all else.
Bristol Royal Infirmary Inquiry; The Stationery Office. London, England: Crown Copyright; 2002.
In June 1998, the Secretary for Health announced to Parliament the organization of a formal Inquiry into children's heart surgery at the Bristol Royal Infirmary between 1984 and 1995. Their objectives included understanding what happened in Bristol, assessing the quality of care and system failures that contributed to deaths, and generating lessons that could be learned for the entire National Health Service (NHS) in the United Kingdom. The inquiry was independent and not held as a legal proceeding, but provided a comprehensive investigation with interviews, expert panels, and a goal of driving improvement efforts. Section one of the report outlines pediatric cardiac surgical services in Bristol while section two focuses on recommendations to ensure high quality care across the NHS. Several publications resulted from the learnings of the Bristol inquiry, including a discussion of cultural entrapment and lessons for quality improvement.
JCAHO; Joint Commission on Accreditation of Healthcare Organizations.
According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.
Boston, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2006.
This consensus paper of the Harvard-affiliated hospitals was prepared by clinicians, risk managers, and patients to provide an in-depth understanding of preventable adverse events, their impact on patients, families, and providers, and how to manage such events. The report provides detailed guidelines based on the premise that all care should be safe and patient-centered and that all actions require full disclosure. In addition to offering recommendations on how to effectively communicate with patients and families, the report discusses support for caregivers and a detailed strategy for institutions to respond to such events in a timely and appropriate fashion. Finally, the comprehensive report offers several appendices that include recommendations and a case study on communicating with patients and families.
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.
Gawande A. New York, NY: Metropolitan Books; 2002. ISBN: 9780805063196.
In Complications, Gawande reprises and builds on a series of feature articles, several written for the New Yorker during his surgical residency at Harvard, exploring the imperfect science of medicine. Part I, Fallibility, explores several patient safety issues. Part II, Mysteries, presents a series of remarkable cases that perplex even the most seasoned clinicians. Lastly, Uncertainty explores the common situations in medicine in which even highly trained physicians are required to act with imperfect knowledge. Written for both practitioners and patients, Complications effectively opens up the fascinating, previously hidden world of surgery to its readers.
Robins NS. New York NY: Delacorte Press; 1995. ISBN: 9780385308090.
Robins, an investigative journalist, recounts the story of Libby Zion, who died at New York Hospital in 1984 allegedly at the hands of under-supervised and overworked residents. The book is an interesting and engaging account of a case and its aftermath, including the highly publicized malpractice trial and the formation of the Bell Commission, which regulated resident work-hours for the first time. The book provides an important historical context for this case and the debate surrounding it, the implications of which are still being felt today in the wake of national regulations for resident duty-hours.
Knox RA. Boston Globe. March 23, 1995; metro/region:1.
This column chronicles the tragic death of Betsy Lehman, a Boston Globe health columnist, who fell victim to an inadvertent overdose of chemotherapy while receiving treatment for breast cancer at the Dana-Farber Cancer Institute. The story details the events surrounding the case, the reactions among family and the public, and the response from Dana-Farber.
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.
Bosk CL.Chicago, IL: University of Chicago Press; 2003. ISBN: 9780226066783.
In this seminal study, Bosk, a medical sociologist at the University of Pennsylvania, spent a year observing the surgical residents and faculty at an unnamed hospital, in the process exploring the balance between autonomy and oversight in medical training, how physicians deal with their errors, and the nature of accountability in the medical profession. This edition, published more than two decades after Forgive and Remember was first published, includes a new prologue, epilogue, and list of appendices. The book is informative for both lay readers and clinicians.
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