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.
Agarwal AK, Sagan C, Gonzales R, et al. J Am Coll Emerg Physicians Open. 2022;3:e12870.
Black patients who report experiencing racism in healthcare report poorer quality of care. In this text-message based study, Black and White patients discharged from the emergency department (ED) were asked about their overall quality of care and whether they perceived an impact of their race on their care. While Black patients reported high overall quality of care, 10% believed their race negatively impacted their care. The authors highlight the importance of asking about the impact of race on care to identify and reduce potential disparities.
Hailu EM, Maddali SR, Snowden JM, et al. Health Place. 2022;78:102923.
Racial and ethnic health disparities are receiving increased attention, and yet structural racism continues to negatively impact communities of color. This review identified only six papers studying the impact of structural racism on severe maternal morbidity (SMM). Despite heterogeneity in measures and outcomes, the studies all demonstrated a link between structural racism and SMM; additional research is required.
Al-Ghunaim TA, Johnson J, Biyani CS, et al. Am J Surg. 2022;224:228-238.
Burnout in healthcare providers has been linked to lower patient safety and increased adverse events. This systematic review examined studies focusing on the relationship between burnout and patient safety and professionalism in surgeons. Results indicate higher rates of burnout and emotional exhaustion were associated with an increased risk of involvement in medical error. Interventions to reduce burnout and improve surgeon well-being may result in improved patient safety.
Rivera-Chiauzzi EY, Smith HA, Moore-Murray T, et al. J Patient Saf. 2022;18:e308-e314.
Peer support programs are increasingly used to support clinicians involved in adverse events. This evaluation found that a structured peer support program for providers involved in obstetric adverse events can effectively support providers in short periods of time (for example, 92% of participants did not need follow-up after second peer support contact) and can be initiated with limited resources.
Improving maternal safety is an ongoing patient safety priority. This systematic review concluded that maternal near miss events are negatively associated with various aspects of quality of life. Women exposed to maternal near miss events were more likely to have overall lower quality of life, poorer mental and social health, and suffer negative economic consequences.
Park Y, Hu J, Singh M, et al. JAMA Netw Open. 2021;4:e213909.
Machine learning uses data and statistical methods to enhance risk prediction models and it has been promoted as a tool to improve healthcare safety. Using Medicaid claims data for a large cohort of White and Black pregnant females, this study evaluated approaches to reduce bias in clinical prediction algorithms for postpartum depression and mental health service utilization. The researchers found that a reweighing method in machine learning models was associated with a greater reduction in bias than excluding race from the prediction models. The authors suggest further examination of potentially biased data informing clinical prediction models and consideration of other methods to mitigate bias.
Avesar M, Erez A, Essakow J, et al. Diagnosis (Berl). 2021;8:358-367.
Disruptive and rude behavior can hinder teamwork and diminish patient safety. This randomized, simulation-based study including attendings, fellows, and residents explored whether rudeness during handoff affects the likelihood for challenging a diagnostic error. The authors found that rudeness may disproportionally hinder diagnostic performance among less experienced physicians.
Brommelsiek M, Said T, Gray M, et al. Am J Surg. 2021;221:980-986.
Silence in the operating room (OR) can have implications on surgical team function and patient safety. Through interviews with interprofessional surgical team members, the authors explored the influence of silence on team action in the OR and found that silence in the surgical environment – whether due to team cohesion or individual defiance – has implications for team functions.
Bender WR, Srinivas S, Coutifaris P, et al. Am J Perinatol. 2020;37:1271-1279.
This cohort explored the mental health impacts of a universal COVID-19 testing program on asymptomatic pregnant women and labor and delivery health care workers. Among multiparous women who tested negative, nearly 35% reported that COVID-19 led to additional fear or anxiety postpartum compared with previous deliveries. Labor and delivery health care workers reported that COVID-19 decreased job satisfaction and increased job-related anxiety.
Fasano HT, McCarter MSJ, Simonis JM, et al. Simul Healthc. 2021;6:85-91.
This study explored disparities in physician decision making among patients of varying socioeconomic status (SES) during simulated scenarios. While quantitative analyses did not identify a significant relationship between SES and image or medication ordering, patient-perceived empathy, or clinical performance, qualitative analyses identified three themes which may bias decision making – overt diagnostic focus, discharge planning, and risk and exposure.
Boudreaux ED, Larkin C, Camargo CA, et al. Jt Comm J Qual Patient Saf. 2020;46:342-352.
This article describes the implementation of the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) Secondary Screener among adult patients at eight emergency departments (EDs) in seven states from August 2010 through November 2013. Of 1,376 patients endorsing active suicidal ideation or recent suicide attempt, most were positive for at least one indicator on the ED-SAFE screener. Based on score, the research team stratified patients at mild-, moderate-, or high-risk for suicide and these strata were associated with significantly different rates of suicidal behavior and attempts after 12 months of follow-up. The researchers recommend additional validation studies and removing elements with less predictive value to increase utility of this screening tool in the ED.
Hajibandeh S, Hajibandeh S, Satyadas T. Surgeon. 2019;18:231-240.
Differences in weekend care for inpatients have been reported; however, the patient safety implications of the weekend effect are unclear. This meta-analysis pooled data from over 390,000 patients and found there was a higher risk of postoperative mortality among patients undergoing emergency general surgery on the weekends in the United States and Europe.
Chrouser KL, Xu J, Hallbeck S, et al. Am J Surg. 2018;216:573-584.
Stressful clinician interactions can diminish the teamwork required to support safe care. This review describes a framework for guiding understanding of how behavioral and emotional responses can affect team behavior, performance, and patient outcomes in the surgical setting. The authors recommend areas of research required to fully understand the phenomenon.
Law AC, Roche S, Reichheld A, et al. Jt Comm J Qual Patient Saf. 2019;45:276-284.
Emotional and psychological harm are understudied but common preventable adverse events. Overt disrespect from health care providers and the lasting psychological impact of safety hazards both contribute to emotional harm. This large, prospective study explored emotional harm among 1559 family members of intensive care unit patients at a hospital in Boston, Massachusetts. About 22% of family members reported inadequate respect toward either themselves or the patient, and more than half of respondents perceived a lack of control over their loved one's care. Inadequate respect and lack of control were strongly correlated with overall satisfaction with care. A WebM&M commentary discussed the utility of family-centered care to preventing harm in the intensive care unit.
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