Classics and Emerging Classics

The AHRQ Patient Safety Indicators (PSIs) represent quality measures that make use of a hospital's available administrative data. The PSIs reflect the quality of inpatient care but also focus on preventable complications and iatrogenic events. Investigators have found PSIs to be a useful tool for understanding adverse events and identifying possible areas of improvement within health care delivery systems. Although relying on administrative data has clear limitations, select PSIs have been shown to accurately identify certain accidental inpatient injuries. The AHRQ Web site offers publicly available comparative data, along with resources and tools. Patient safety measurement methods are discussed in an AHRQ WebM&M perspective. Originally released in 2005, the PSI were most recently updated in August 2023.

Drawing on information gathered from the ISMP Medication Errors Reporting Program, this fact sheet provides a comprehensive list of commonly confused medication names, including look-alike and sound-alike name pairs. Drug name confusion can easily lead to medication errors, and the ISMP has recommended interventions such as the use of tall man lettering in order to prevent such errors. An error due to sound-alike medications is discussed in this AHRQ WebM&M commentary.

Effective teamwork plays an essential role in providing safe patient care. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was developed inititally in collaboration by the United States Department of Defense and AHRQ in order to support effective communication and teamwork in health care. The 3.0 version of the widely implemented program is organized around 5 key strategies: patient focus, integrated platform, modular course design, active adult learning and emergent team challenges and opportunities. It provides new tools to measure its impact, supports increased emphasis on the role of patients in teams, and includes a new pocket guide. A PSNet WebM&M commentary discussed how improved teamwork and shared decision-making might have prevented a missed diagnosis of sepsis that lead to the death of a patient.

Culture has been described as a key to establishing high reliability organizations. The National Quality Forum's Safe Practices for Healthcare and the Leapfrog Group both mandate hospitals to regularly assess their safety culture. This AHRQ Web site provides validated safety culture survey tools (Hospital, Medical Office, Nursing Home, Community Pharmacy, Ambulatory Surgery Center), user guides health care organizations can use to implement the surveys and a bibliography of articles discussing the use of SOPS in the field. Organizations can also use the AHRQ database to compare their Surveys on Patient Safety Culture™ (SOPS®) results. In addition, reports are available that summarize the benchmarking data across cohorts nationwide. An AHRQ WebM&M perspective discussed how to establish a safety culture.

Health literacy is a social determinant of health and can affect the ways people understand and interact with the health system. This review describes categories of health literacy, how it functions as a social determinant of health, and interventions to improve health literacy at system, community, and individual levels.

Fatigue among health care workers can increase the risk of errors. This large cross-sectional study of attending and house staff physicians found that sleep-related impairment was associated with increased burnout, decreased professional fulfillment, and increased self-reported clinically significant medical error. Organizational policies should focus on reducing sleep-related impairment in order to reduce harm to patients and physicians.

Pulse oximetry is used to triage patients, initiate or adjust oxygen administration, and, more recently, as a way to remotely monitor COVID-19 patients at home. However, a study in the Johns Hopkins Health System showed that Asian, Black, or Hispanic patients are more likely to experience inaccurate readings, potentially resulting in missed or delayed diagnosis of respiratory diseases. This study used paired oxygen saturation by pulse oximetry and arterial oxygen saturation in arterial blood gas in Black and white patients before and during the COVID-19 pandemic. Consistent with the Johns Hopkins study, Black patients had three times the frequency of occult hypoxia than white patients.

Electronic prescribing systems (such as computerized provider order entry) can aid in medication reconciliation and prevent medication errors. In this systematic review, the authors found variable evidence about the effectiveness of these systems for medication error and harm reduction. Included studies reported reductions in error rates, but implementation of electronic systems did not result in less patient harm.

Social distancing precautions due to the COVID-19 pandemic have led to increased use of telehealth. The authors of this systematic review conclude that there is insufficient evidence to determine whether remote prescribing in primary care changes antibiotic prescribing practices. Future research should further assess remote prescribing to ensure there are no negative impacts on antimicrobial stewardship.  

This special collection examines the use of novel health information technology (HIT) to promote patient safety and challenges in examining the impact of those technologies. Articles featured in this issue include a focus on qualitative approaches to evaluating the impact of HIT on patient safety, particularly through a sociotechnical lens.

The COVID-19 pandemic has raised concerns about medical product shortages and demand surges, and the resulting effects on patient safety. This viewpoint discusses medical product supply chain vulnerabilities heightened by the COVID-19 pandemic. The authors summarize the evidence on supply chain resilience and medical product shortage, provide examples to illustrate key vulnerabilities, and discuss reactive and proactive solutions for medical product shortage.

The COVID-19 pandemic has dramatically affected the psychological and emotional well-being of health care workers. This article summarizes the COVID-19-related psychological effects on healthcare workers and the detrimental impact on team effectiveness. The authors recommended actions to mitigate the effects of stress on team performance and patient outcomes and discuss how teams can recover and learn from the current crisis to prepare for future challenges.

Debriefing is an established strategy teams use to learn from critical events, reduce event occurrence, and improve failure response. This review examines how debriefing principles can be embedded for use of the practice in real time, rather than developed in simulated circumstances, to improve anesthesia safety.

Machine learning can improve the accuracy of clinical decision support (CDS) tools. This single-site study used data from the electronic health record (EHR) and clinical pharmacist review to test the accuracy of a hybrid CDS system to identify prescriptions with high risk of medication error. The machine-learning based approach was more accurate than existing techniques such as the traditional CDS system and can improve the reliability of prescription checks in an inpatient setting.  

This article discusses the evidence base on operational measurement of diagnostic safety and how health care organizations can measure and learn from diagnostic errors to improve patient safety.

This study used ecological systems theory to review the literature on the root causes of racial disparities in maternal morbidity and mortality at the individual, interpersonal, community, and societal levels. Factors influencing disparities include access to preconception and prenatal care, implicit bias among health care providers, the need for quality improvement among black-serving hospitals, and policies such as parental leave. The authors also identify interventions likely to reduce disparities, such as improving health professional education, alternate prenatal care providers, and reforming Medicaid policies.

This article describes the development of the “Swiss cheese model,” (SCM) and the main criticisms of this model and the motivation for these criticisms.  The article concludes that the SCM remains a relevant model because of its systemic foundations and its sustained use in high-risk industries and encourages safety science researchers and practitioners to continue imagining alternatives combining empirical, practical and graphical approaches.

The authors analyzed National Surgical Quality Improvement Program (NSQIP) Pediatric data from 2012 through 2017 to explore racial differences in postsurgical complications among healthy children. Compared to white children, African American children were three times as likely to die within 30 days after surgery and were more likely to develop postoperative complications and serious adverse events. These results can help guide future research exploring the mechanisms underlying racial differences in postsurgical outcomes in children.

This study evaluated the impact of an electronic decision support tool comprising a comprehensive drug review to support deprescribing and reduce polypharmacy in elderly adults. Results indicate that the tool did reduce the number of prescribed drugs but did not significantly reduce unplanned hospital admissions or death after 24 months.

This systematic review of 54 studies found that over half of adult and pediatric patients experienced a medication error post-discharge, and that these errors regularly involved common drug classes such as antibiotics, antidiabetics, analgesics, and cardiovascular drugs. The authors suggest that future research examine the burden of post-discharge medication errors, particularly in pediatric populations.