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.
Wilson M-A, Sinno M, Hacker Teper M, et al. J Patient Saf. 2022;18:680-685.
Achieving zero preventable harm is an ongoing goal for health systems. In this study, researchers developed a five-part strategy to achieve high-reliability and eliminate preventable harm at one regional health system in Canada – (1) engage leadership, (2) develop an organization-specific patient safety framework, (3) monitor specific quality aims (e.g., high-risk, high-cost areas), (4) standardize the incident review process, including the use of root cause analysis, and (5) communicate progress to staff in real-time via electronic dashboards. One-year post-implementation, researchers observed an increase in patient safety incident reporting and improvements in safety culture, as well as decreases in adverse events such as falls, pressure injuries and healthcare-acquired infections.
Computed tomography (CT) scans are important diagnostic tools but can present serious dangers from overexposure to radiation. Researchers reviewed 133 radiation incidents reported to one NHS trust from 2015-2018. Reported events included radiation incidents, near-miss incidents, and repeat scans. Most events were investigated using a systems approach, and staff were encouraged to report all types of incidents, including near misses, to foster a culture of safety and enable learning.
Plunkett A, Plunkett E. Paediatr Anaesth. 2022;32:1223-1229.
Safety-I focuses on identifying factors that contribute to incidents or errors. Safety-II seeks to understand and learn from the many cases where things go right, including ordinary events, and emphasizes adjustments and adaptations to achieve safe outcomes. This commentary describes Safety-II and complementary positive strategies of patient safety, such as exnovation, appreciative inquiry, learning from excellence, and positive deviance.
Chang ET, Newberry S, Rubenstein LV, et al. JAMA Network Open. 2022;5:e2224938.
Patients with chronic or complex healthcare needs are at increased risk of adverse events such as rehospitalization. This paper describes the development of quality measures to assess the safety and quality of primary care for patients with complex care needs at high risk of hospitalization or death. The expert panel proposed three categories (assessment, management, features of healthcare), 15 domains, and 49 concepts.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.
Samal L, Khasnabish S, Foskett C, et al. J Patient Saf. 2022;18:611-616.
Adverse events can be identified through multiple methods, including trigger tools and voluntary reporting systems. In this comparison study, the Global Trigger Tool identified 79 AE in 88 oncology patients, compared to 21 in the voluntary reporting system; only two AE were identified by both. Results indicate multiple sources should be used to detect AE.
Hemmelgarn C, Hatlie MJ, Sheridan S, et al. J Patient Saf Risk Manage. 2022;27:56-58.
This commentary, authored by patients and families who have experienced medical errors, argues current patient safety efforts in the United States lack urgency and commitment, even as the World Health Organization is increasing its efforts. They call on policy makers and safety agencies to collaborate with the Patients for Patient Safety US organization to move improvement efforts forward.
Lalani M, Morgan S, Basu A, et al. J Health Serv Res Policy. 2022;Epub May 6.
Autopsies following unexpected deaths can provide valuable insights and learning opportunities for improving patient safety. In 2017, the National Health Service (NHS) implemented “Learning from Deaths” (LfD) to report, learn from, and avoid potentially preventable deaths. Through interviews with policy makers, managers, and senior clinicians responsible for implementing the policy, this study reports on how contextual factors influenced implementation of the LfD policy.
Shah F, Falconer EA, Cimiotti JP. Qual Manag Health Care. 2022;31:231-241.
Root cause analysis (RCA) is a tool commonly used by organizations to analyze safety errors. This systematic review explored whether interventions implemented based on RCA recommendations were effective at preventing similar adverse events in Veterans Health Affairs (VA) settings. Of the ten retrospective studies included in the review, all reported improvements following RCA-recommended interventions implementation, but the studies used different methodologies to assess effectiveness. The authors suggest that future research emphasize quantitative patient-related outcome measures to demonstrate the impact and value of RCAs.
National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021.
Maternal safety is challenged by clinical, equity, and social influences. This virtual event examined maternal health conditions in the United States to improve health system practice and performance for this population. Discussions addressed the need for better data collection, evidence-based practice, and social determinants knowledge integration to enhance the safety of care.
Serou N, Sahota LM, Husband AK, et al. Int J Qual Health Care. 2021;33:mzab046.
High reliability organizations consistently examine and learn from failures. This systematic review identified several effective learning tools that can be adapted and used by multidisciplinary health care teams following a patient safety incident, including debriefing, simulation, crew resource management, and reporting systems. The authors concluded that these tools have a positive impact on learning if used soon after the incident but further research about successful implementation is needed.
Disclosure of and communication about errors and adverse events is increasingly encouraged in health care. This position paper discusses the key elements for effective communication about medical errors with patients and families and the importance of disclosure education in medical training, including the development of nonverbal skills.
Patients and families that experience medical harm have unique support needs. This organization works to improve health system and clinician response to harmed patients. Their efforts aim to create a deeper understanding of the factors contributing to lack of response to concerns to enhance existing processes.
Azam I, Gray D, Bonnett D et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2021. AHRQ Publication No. 21-0012.
The National Healthcare Quality and Disparities Reports review analysis specific to tracking patient safety challenges and improvements across ambulatory, home health, hospital, and nursing home environments. The most recent Chartbook documented improvements in approximately half of the patient safety measures tracked. This set of tools includes summaries drawn from the reports for use in presentations to enhance distribution and application of the data.
Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021;17:30-35.
Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.
Preventable harm, such as diagnostic and medication errors, threaten patient safety in ambulatory care settings. This article discusses the scientific, practice, policy, and patient/family milestones necessary to accelerate progress in reducing preventable harm among outpatients and advance ambulatory safety. The authors recommend numerous key milestones, including improving measurement methods, routine monitoring of safety for improvement and learning, leveraging patient engagement, and a national patient safety center to coordinate and lead ambulatory safety efforts.
Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, et al. J Patient Saf. 2021;17:e20-e27.
Patient safety in primary care is an emerging focus. This cross-sectional study across primary care clinics in England explored the main factors contributing to patient-reported harm experiences. Factors included incidents related to communication, care coordination, and incorrect or delayed; diagnosis and/or treatment.
Kundu P, Jung OS, Valle LF, et al. Pract Radiat Oncol. 2021;11:e256-e262.
Underreporting of ‘near misses’ can impede efforts to improve healthcare quality and patient safety. Based on hypothetical scenarios involving a patient with a cardiac pacemaker undergoing radiation treatment, this study surveyed healthcare staff about their evaluation of the events and their willingness to report based on their evaluation of the hypothetical scenarios. Findings suggest that cognitive biases can influence willingness to report based on how near miss events are perceived.
Gallagher TH, Boothman RC, Schweitzer L, et al. BMJ Qual Saf. 2020;29:875-878.
Communication-and-resolution programs (CRP) emphasize early disclosure of adverse events and proactive approaches to resolving patient safety issues. This editorial discusses strategies for successful implementation of CRPs highlighted in prior research, including its prioritization by institutional leadership, investment in tools and resources necessary for implementation, and the use of metrics to track CRP functioning.
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