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.
Gillissen A, Kochanek T, Zupanic M, et al. Diagnosis (Berl). 2022;Epub Nov 9.
Medical students do not always feel competent when it comes to patient safety concepts. In this study of German medical students, most understood the importance of patient safety, though few could identify concrete patient safety topics, such as near miss events or conditions that contribute to errors. Incorporating patient safety formally into medical education could improve students’ competence in these concepts.
Świtalski J, Wnuk K, Tatara T, et al. Int J Environ Res Public Health. 2022;19:15354.
Improving patient safety in long-term care facilities is an ongoing challenge. This systematic review identified three types of interventions that can improve safety in long-term care facilities – (1) promoting safety culture, (2) reducing occupational stress and burnout, and (3) increasing medication safety.
Lucas SR, Pollak E, Makowski C. J Healthc Risk Manag. 2022;Epub Dec 4.
Medical errors that receive widespread media attention frequently spur health systems to reexamine their own culture and practices to prevent similar errors. This commentary describes one health system’s effort to identify and improve the system factors (systems, processes, technology) involved in the error. The action plan proposed by this project includes ensuring a just culture so staff feel empowered to report errors and near-misses; regularly review and improve medication delivery systems; build resilient medication delivery systems; and, establish methods of investigations.
Pado K, Fraus K, Mulhem E, et al. J Clin Psychol Med Settings. 2022;Epub Dec 12.
Medical errors may lead to feelings of distress for clinicians, but these errors can also be an opportunity for growth. This study used the Second Victim Experience and Support Tool (SVEST) and the Posttraumatic Growth Inventory to assess the extent, if any, of growth following a medical mishap. Rumination and the impact of the medical mishap were associated with distress among both physicians and nurses. The impact of the event was associated with growth in nurses, but no factor was associated with growth in physicians.
The criminal conviction of a nurse involved in a medical error has raised concerns about a possible negative impact on error disclosure. This article discusses the ethical and legal considerations related to this prosecution and the association with patient safety.
Mahat S, Rafferty AM, Vehviläinen-Julkunen K, et al. BMC Health Serv Res. 2022;22:1474.
Healthcare staff who are involved in a medical error often experience emotional distress. Using qualitative methods and text mining of medication error incident reports, researchers in this study identified the negative emotions experienced by healthcare staff after a medication error (e.g., fear, guilt, sadness) and perceptions regarding how superiors and colleagues effectively responded to the events (e.g., reassurance, support, and guidance).
Feldman N, Volz N, Snow T, et al. J Patient Saf Risk Manag. 2022;27:229-233.
Research with medical and surgical residents has shown they are frequently reluctant to speak up about safety and unprofessional behavior they observe. This study asked emergency medicine residents about their speaking up behaviors. Using the Speaking Up Climate (SUC)-Safe and SUC-Prof surveys, residents reported generally neutral responses to speaking up, more favorable than their medical and surgical counterparts. In line with other studies, residents were more likely to speak up about patient safety than about unprofessional behaviors.
Leitman IM, Muller D, Miller S, et al. JAMA Netw Open. 2022;5:e2244661.
The effectiveness of incident reporting systems is hindered by underreporting. This cohort study describes the characteristics of incident reports submitted by trainees in a large academic medical center. From October 2019 through December 2021, trainees submitted nearly 200 incident reports, primarily describing unprofessional interactions. Findings suggest that awareness and support for the online incident reporting system among trainees was high.
Crunden EA, Worsley PR, Coleman SB, et al. Int J Nurs Stud. 2022;135:104326.
Hospital-acquired pressure ulcers, categorized as a never event, are underreported, particularly when related to medical devices. Interviews with experts in hospital-acquired pressure ulcers revealed four domains related to reporting: 1) individual health professional factors, 2) professional interactions, 3) incentives and resources, and 4) capacity for organizational change. Teamwork, openness, and feedback were seen as the main facilitators to reporting, and financial consequences was a contributing barrier.
Hunt J, Gammon J, Williams S, et al. BMC Health Serv Res. 2022;22:1446.
Isolation for infection prevention and control may result in unintended consequences for patient safety. Using focus groups at two hospitals, this study explored healthcare staff understanding of infection prevention practices and patient safety culture within insolation settings. Thematic analysis highlights the importance of engaged leadership, appropriate staffing, teamwork, and prioritization of patient-centered care in achieving a culture of safety and improvements in infection prevention.
Kim K-A, Lee J, Kim D, et al. BMC Health Serv Res. 2022;22:1376.
Safety culture has been shown to be associated with nursing home quality indicators such as discharge to community and injuries related to falls and catheters. Numerous surveys exist to measure safety culture. This review identified seven measurement tools, and the most frequently used tool was the Nursing Home Survey on Patient Safety Culture. The Hospital Survey on Patient Safety Culture, Safety Attitudes Questionnaire, and Modified Stanford Patient Safety Culture Survey Instrument were also used.
Kim S, Lynn MR, Baernholdt MB, et al. J Nurs Care Qual. 2022;38:11-18.
In response to concerns about workplace violence (WPV) directed at healthcare workers in the US, the Joint Commission issued a Sentinel Event Alert and recommendations to increase organizational awareness of this risk. This study evaluated the effect of one of those recommendations, a WPV-reporting culture, on nurses’ burnout and patient safety. As anticipated, WPV increased nurse burnout, but unexpectedly, a strong WPV-reporting culture also increased the negative effect of WPV on burnout.
Temkin-Greener H, Mao Y, McGarry B, et al. J Am Med Dir Assoc. 2022;23:1997-2002.e3.
Long-term care facilities can struggle with establishing a safety culture. Researchers in this study adapted the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey to assess patient safety culture in assisted living facilities. Findings show that direct care workers had significantly worse perceptions of patient safety culture (including nonpunitive responses to mistakes, management support for resident safety, and teamwork) compared to administrators. A PSNet perspective discusses how to change safety culture.
Work-related psychosocial factors may increase or decrease the risk of accidents in high-risk industries (e.g., nuclear, mining, healthcare). Using the Job Demands-Resources (JD-R) framework as a starting point, associations between job demands and resources, and between safety behaviors and outcomes were evaluated. Most studies report on the link between psychosocial factors and safety behavior (e.g., job stress or exhaustion can precede negative safety behavior).
Gogalniceanu P, Karydis N, Costan V-V, et al. J Am Coll Surg. 2022;235:612-623.
Safety strategies from high-reliability industries such as aviation and nuclear power are frequently adapted for healthcare. In this study, pilots described crisis preparedness strategies, which surgical safety experts then developed into a framework consisting of six behavioral interventions: anticipate threats, briefing, checklists, drill rehearsal, individual and team empowerment, and debriefing. An earlier study by the authors describes the second phase in managing crisis: crisis recovery.
Healthcare trainees and junior clinicians are often reluctant to speak up about safety concerns. This qualitative study found that simulation training to enhance speaking up behaviors had lasting effects among advanced care paramedics and respiratory therapists as they moved from training into practice. Respondents highlighted the importance of experience for speaking up and the benefits of high-impact simulation training.
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.
Silva B, Ožvačić Adžić Z, Vanden Bussche P, et al. Int J Environ Res Public Health. 2022;19:10515.
The COVID-19 pandemic led to dramatic changes in healthcare delivery. The multi-country PRICOV-19 study evaluated how primary care practices reorganized their day-to-day work during the pandemic and the impacts on patient safety culture. This study compared training vs. non-training primary care practices and found that training practices had a stronger safety culture during the pandemic.
Cartland J, Green M, Kamm D, et al. BMJ Open Qual. 2022;11:e001757.
Psychological safety is a cornerstone of high reliability organizations (HROs). This children’s hospital developed two scales (trust in team members and trust in leadership) and one composite measure (local learning) to measure staff psychological safety and evaluate the effectiveness of their transition to high reliability. More than 4,500 health system staff completed the survey; results indicate the two scales are strongly associated with the composite measure.
McCain N, Ferguson T, Barry Hultquist T, et al. J Nurs Care Qual. 2023;38:26-32.
Daily huddles can improve team communication and awareness of safety incidents. This single-site study found that implementation of daily interdisciplinary huddles increased reporting of near-miss events and improved team satisfaction and perceived team communication, collaboration, and psychological safety.
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