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.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.
Trenton, NJ: New Jersey Department of Health and Senior Services.
Detailing results of an error reporting initiative in New Jersey, these reports explain how consumers can use this information and provides tips for safety when obtaining health care. A section highlights findings related to patient safety indicators.
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene.
This annual report summarizes never events in Maryland hospitals over the previous year. From July 2020-June 2021, reported events increased due to the COVID pandemic. Pressure injuries increased and patient deaths from preventable medical errors doubled in the time period. The authors recommend several corrective actions to build on training and policy changes to guide improvement work, including engaging leadership in safety work and application of high-reliability concepts to enhance safety culture.
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2020.
This reoccurring report compiles patient safety data documented by Massachusetts hospitals. The 2019 numbers represent a modest increase in serious reportable events recorded in acute care hospitals, from 1066 the previous year to 1189. This presentation also includes events from ambulatory surgery centers. Older reports are also available.
Rensselaer, NY: Healthcare Association of New York State; November 2019.
This publication assessed 12 widely disseminated hospital report cards by criteria including transparency of methodology, evidence-based measures, and data quality. While inconsistent methods across reports hindered direct comparisons, a few reports received high marks.
The Pennsylvania Patient Safety Authority is a long-established source of patient safety data analysis and application-focused commentary. Their publishing output aims to generate improvements in their state as well as throughout health care. This open-access publication replaces the quarterly Pennsylvania Patient Safety Advisory newsletter.
Pettersen B, Tate J, Tipper K, McKean H. Colorado Senate Bill 19-201.
Communication-and-resolution mechanisms are seen as important approaches to improving transparency and healing after an adverse event. This state bill, referred to as the "Colorado Candor Act," protects conversations between organizations, clinicians, patient, and families from legal discoverability and outlines criteria to guarantee that protection.
This article analyzed 2017 data submitted to the Pennsylvania Patient Safety Authority to document age-related patterns of patient harm in Pennsylvania hospitals. Complications were highly associated with serious harm that unexpectedly declined in patients of advanced age.
Hendricks R, O'Neil M, Volmert A. Boston, MA: Betsy Lehman Center for Patient Safety; March 2019.
This report suggests that the field of patient safety needs to be reframed for the public. The report recommends that patient safety professionals, experts, and advocates define patient safety, explain the prevalence of medical errors, and describe solutions. The authors emphasize that sharing the systems approach to improvement can help patients understand how patient safety issues can be prevented. They encourage continued use of the aviation metaphor to illustrate why medical errors occur and how to address them. The authors urge patient involvement with a focus on concrete activities, but they recommend avoiding the term "patient empowerment." An Annual Perspective discussed how patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.
Gipson K. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):39-45.
Patients are increasingly seen as partners in efforts to improve health care safety. This article discusses insights gleaned from a survey of 606 Pennsylvania residents regarding patient perceptions of their ability to enhance diagnostic processes.
Deutsch E, ed. PA-PSRS Pa Patient Saf Advis. 2018 Oct 31;15(suppl 1):1-70.
This special issue raises awareness of challenges to reducing diagnostic error. Articles discuss insights from experts about how to improve diagnosis, the role of patients in diagnostic error reduction, and diagnostic process improvement activities implemented in various health care facilities.
Triller D, Myrka A, Gassler J, et al. Jt Comm J Qual Patient Saf. 2018;44:630-640.
Patients prescribed high-risk medications, including anticoagulants, are at increased risk for adverse drug events and may be particularly vulnerable during care transitions. This study describes how a multidisciplinary panel of anticoagulation experts used an iterative consensus-building process to determine what information should be communicated to relevant providers for all patients on anticoagulation undergoing a transition in care.
Kentucky Institute for Patient Safety and Quality; KIPSQ.
The Kentucky Institute for Patient Safety and Quality offers the support of a patient safety organization and educational opportunities to foster safety and quality improvement throughout the state. Services provided include Safe Table events, data analysis, and peer review consultations.
This advisory from the Pennsylvania Patient Safety Reporting System discusses 1079 reports of tourniquets being inappropriately left on patients and provides strategies to reduce these occurrences. This is the third in a series of articles on this topic from the Authority.
St Paul, MN: Minnesota Department of Health; 2015.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.
The Betsy Lehman Center is a nonregulatory Massachusetts state agency named for Betsy Lehman, the Boston Globe columnist who died due to an inadvertent chemotherapy overdose. The Center works to support a statewide program coordinating health care organization and provider efforts to reduce medical errors, enabling patients to participate in safety improvement, and disseminating information about best practices.
Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.
Health literacy can affect patients' ability to understand directions, ask good questions, and participate in care. Framing health literacy as a public health challenge, this report describes efforts to address it in three states and explores implementation and research to improve it across the United States.
Feil M. PA-PSRS Patient Saf Advis. June 2014;11:45-52.
Operating rooms are complex environments with particular risks regarding interruptions and distractions. This article draws from data reported to the Patient Safety Authority to explore how distractions affect surgeons and other team members. The author reviews strategies to limit distractions, including applying sterile cockpit principles, performing preoperative briefings, and utilizing checklists.
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