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.
Although recommended as a patient safety improvement strategy, the value of root cause analysis has been debated. This commentary suggests a three-step approach for optimizing root cause analysis results to detect factors that contribute to adverse events. The author applies philosophical principles to identify and prioritize interventions to enhance benefit from root cause analysis.
Boyd M, Cumin D, Lombard B, et al. BMJ Qual Saf. 2014;23:989-93.
Read-backs are widely recommended in order to improve communication of critical clinical information. This simulation study found that anesthesiologists who immediately read back clinical data during simulated emergencies were eight times more likely to retain and use the information appropriately.
Dawson S, King L, Grantham H. Emerg Med Australas. 2015;25:393-405.
Handoffs between care settings can lead to adverse events. This literature review analyzed 17 studies of handoffs between prehospital first responders and emergency department (ED) staff. Safety gaps detected included communication barriers, lack of a structured communication tool, and unclear identification of the receiving clinical staff. The authors suggest that a structured handoff tool could improve first responder–ED handoffs. A past AHRQ WebM&M commentary discussed communication failures between providers and highlighted a need for standard handoff protocols.
Klim S, Kelly A-M, Kerr D, et al. J Clin Nurs. 2013;22:2233-43.
In this mixed-methods study of nursing handoffs in the emergency department, 96% of participants felt that they received adequate information. Participating nurses believed that the essential data included demographics, presenting problems, nursing observations, and future care plans.
Iedema R, Ball C, Daly B, et al. BMJ Qual Saf. 2012;21:627-33.
Prior research has documented errors in handoffs between ambulance and emergency department personnel. This study reports on the development and initial implementation of a structured tool for use at this handoff.
Lu CY, Roughead E. Int J Clin Pract. 2011;65:733-40.
Poor care coordination has been shown to be a risk factor for preventable errors in the ambulatory setting, and patients consistently voice concern about care coordination problems. This survey, which builds on prior Commonwealth Fund reports, found that care coordination was a major determinant of patient-reported medication errors in all seven countries studied. The study reinforces the role of health systems in ambulatory patient safety, and the need for improved communication between providers and better integration of health systems to reduce preventable errors for outpatients.
Paterson R. Auckland, NZ; Office of the Health and Disability Commissioner: April 2007.
This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.
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