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Perspectives on Safety > Annual Perspective
with commentary by Rachel J. Stern, MD, and Urmimala Sarkar, MD, 2018
Patient engagement is widely acknowledged as a cornerstone of patient safety. Research in 2018 demonstrates that patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
Rockville, MD: Agency for Healthcare Research and Quality; February 2005. AHRQ Publication Nos. 050021 (1-4).
With 4 volumes and 140 articles (all of which are freely available through the link below), this expansive collection of literature illustrates the progress made since the 1999 Institute of Medicine's report, To Err is Human: Building a Safer Health System. The efforts represent a successful collaboration between the Agency for Healthcare Research and Quality and the Department of Defense-Health Affairs in meeting the challenge of improving patient safety knowledge, research, and implementation.
Rockville, MD: Agency for Healthcare Research and Quality; July 2008. AHRQ Publication Nos. 080034 (1-4).
The 115 articles freely available in this latest issue of AHRQ's Advances in Patient Safety represent the state of the art in patient safety. Serving as an update and extension to the prior volume, the articles are grouped into four major content areas—assessment, culture and redesign, performance and tools, and technology and medication safety—and are freely available online through the link below.
Journal Article > Commentary
Raju TN, Suresh G, Higgins RD. Pediatr Res. 2011;70:109-115.
This article provides practice and research recommendations to address patient safety issues in neonatal intensive care.
Valdez RS, Ramly E, Brennan PF. Rockville, MD: Agency for Healthcare Research and Quality; May 2010. AHRQ Publication No. 10-0079-EF.
This workshop report explores why efforts to apply industrial and systems engineering (ISyE) knowledge to health care have been generally unsuccessful and suggests a research and action agenda using ISyE knowledge to create an ideal health care delivery system.
Special or Theme Issue
Paasche-Orlow MK, Wilson EAH, McCormack L, eds. J Health Comm. 2010;15(suppl 2):1-225.
This special issue presents findings from a 2009 conference that explored health literacy research in areas such as measurement improvement, informed consent, and organizational communication.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. March 9, 2016. Publication No.NOT-HS-16-009.
Journal Article > Commentary
Russo E, Sittig DF, Murphy DR, Singh H. Healthc (Amst). 2016;4:285-290.
Using a case study on missed and delayed follow-up of test results, this commentary explores challenges and opportunities that data from electronic health records present for patient safety research. Key barriers to utilizing electronic health record data to inform improvement work include restricted access to data, difficulty interpreting data, and workforce issues.
Journal Article > Study
Bezemer J, Cope A, Korkiakangas T, et al. BMJ Qual Saf. 2017;26:583-587.
Journal Article > Review
Murphy DR, Meyer AN, Sittig DF, Meeks DW, Thomas EJ, Singh H. BMJ Qual Saf. 2019;28:151-159.
Identifying and measuring diagnostic error remains an ongoing challenge. Trigger tools are frequently used in health care to detect adverse events. Researchers describe the Safer Dx Trigger Tools Framework as it applies to the development and implementation of electronic trigger tools that use electronic health record data to detect and measure diagnostic error. The authors suggest that by identifying possible diagnostic errors, these tools will help elucidate contributing factors and opportunities for improvement. They also suggest that, if used prospectively, such tools might enable clinicians to take preventive action. However, to design and implement these electronic trigger tools successfully, health systems will need to invest in the appropriate staff and resources. A past PSNet perspective discussed ongoing challenges associated with diagnostic error.
Journal Article > Commentary
Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety.
Bates DW, Singh H. Health Aff (Millwood). 2018;37:1736-1743.
The release of the Institute of Medicine's To Err Is Human in 1999 represented a seminal moment in patient safety and is considered by many to have launched the modern patient safety movement. The report highlighted the incidence of medical errors and preventable deaths in the United States and catalyzed research to identify interventions for improvement. The authors reflect on progress since its publication and suggest that while many effective interventions have been developed for addressing safety challenges such as hospital-acquired infections and medication errors, successful implementation of these solutions remains difficult, and improvement in other areas has been less consistent. In addition, new safety challenges have emerged in the last 20 years including those related to ambulatory care and diagnostic error. The authors conclude that preventable harm remains significant and advocate for enhanced use of widely available electronic data to develop improved interventions for what they foresee may be a Golden Era of swift progress in patient safety. A PSNet perspective reflected on patient safety progress in surgery.
The Moore Foundation provides free access to this article.
Jha AK, Iliff AR, Chaoui AA, Defossez S, Bombaugh MC, Miller YA. Waltham, MA: Massachusetts Medical Society, Massachusetts Health and Hospital Association, Harvard T.H. Chan School of Public Health, and Harvard Global Health Institute; 2019.
Clinician well-being affects the safety of the care environment. This publication suggests that the ramifications of physician burnout are a public health concern. The report provides an overview of the burnout crisis and recommends strategies to address the problem, including mental health initiatives, electronic health record enhancements, and appointment of chief wellness officers.
Notice of Intent to Publish Funding Opportunity Announcement to Improve Care Transitions Through the Use of Interoperable Health Information Technology (R01).
Rockville, MD: Agency for Healthcare Research and Quality; January 28, 2019. AHRQ Publication No. NOT-HS-19-009.
The introduction of information technology has transformed health care. This notice of intent from AHRQ announces an upcoming funding opportunity to support research exploring the adoption of interoperable information technologies to improve communication during transitions. The pending funding will help to refine and develop methods to assess implementation success.
Lau F, Bartle-Clar JA, Bliss G, et al, eds. Stud Health Technol Inform. 2019;257:1-539. ISBN: 9781614999508.
Information technology is prevalent in health care and is associated with both optimized processes and unintended consequences. This publication is a compilation of papers from an international conference that explored the potential of health information technology and the research needed to achieve success. Topics covered include usability, implementation, interoperability, and policy.
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.
Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.