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.
Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.
Urquhart A, Yardley S, Thomas E, et al. J R Soc Med. 2021;114:563-574.
This mixed-methods study analyzed patient safety incident reports between 2005-2015 to characterize the most frequently reported incidents resulting in severe harm or death in acute medical units. Of the 377 included reports, diagnostic errors, medication-related errors, and failure to monitor patient incidents were most common. Patients were at highest risk during handoffs and transitions of care. Lack of active decision-making during admission and communication failures were the most common contributors to incidents.
Murff HJ, FitzHenry F, Matheny ME, et al. JAMA. 2011;306:848-55.
Many adverse event identification methods cannot detect errors until well after the event has occurred, as they rely on screening administrative data or review of the entire chart after discharge. Electronic medical records (EMRs) offer several potential patient safety advantages, such as decision support for averting medication or diagnostic errors. This study, conducted in the Veterans Affairs system, reports on the successful development of algorithms for screening clinicians' notes within EMRs to detect postoperative complications. The algorithms accurately identified a range of postoperative adverse events, with a lower false negative rate than the Patient Safety Indicators. As the accompanying editorial notes, these results extend the patient safety possibilities of EMRs to potentially allow for real time identification of adverse events.