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.
Abramovich I, Matias B, Norte G, et al. Eur J Anaesthesiol. 2023;40:587-595.
Fatigue and sleep deprivation of anesthesia providers can result in decreased non-technical skills and psychomotor functioning. This study of 1,200 anesthesia and intensive care trainees in Europe describes the impact of work-related fatigue on well-being, commuting, and potential for medical errors. Two-thirds of respondents reported making or nearly making a medical error after working long hours. In addition to implementing shorter work schedules, the authors also encourage a culture where it is acceptable to admit fatigue, and where resting is encouraged.
Cortegiani A, Ippolito M, Lakbar I, et al. Eur J Anaesthesiol. 2023;40:326-333.
A simulation study in 2017 showed anesthesia residents performed worse when sleep-deprived after working a night shift. In this quantitative study of more than 5,000 European anesthesiologists, participants reported that working night shifts reduced their quality of life and put their patients at risk. Few reported institutional support (e.g., training, fatigue monitoring) for night shift workers. Importantly, this study reports on perceived risk to patients, not actual patient risk.
Tawfik DS, Adair KC, Palassof S, et al. Jt Comm J Qual Patient Saf. 2023;49:156-165.
Leadership across all levels of a health system plays an important role in patient safety. In this study, researchers administered the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey to 31 Midwestern hospitals to evaluate how leadership behaviors influenced burnout, safety culture, and engagement. Findings indicate that local leadership behaviors are strongly associated with healthcare worker burnout, safety climate, teamwork climate, workload, and intentions to leave the job.
The COVID-19 pandemic increased symptoms of physician burnout, including emotional exhaustion, which can increase patient safety risks. This cross-sectional study examined emotional exhaustion among healthcare workers at two large health care systems in the United States before and during the COVID-19 pandemic. Respondents reported increases in emotional exhaustion in themselves and perceived exhaustion experienced by their colleagues. The researchers found that emotional exhaustion was often clustered in work settings, highlighting the importance of organizational climate and safety culture in mitigating the effects of COVID-19 on healthcare worker well-being.
Adair KC, Heath A, Frye MA, et al. J Patient Saf. 2022;18:513-520.
… J Patient Saf. … Psychological safety (PS) is integral to … asking questions and raising patient safety concerns. A novel PS assessment was administered to over 10,000 … staff in one academic health system. The scale showed a significant correlation with safety culture, especially …
Rehder KJ, Adair KC, Eckert E, et al. J Patient Saf. 2023;19:36-41.
Teamwork is an essential component of patient safety. This cross-sectional study of 50,000 healthcare workers in four large US health systems found that the teamwork climate worsened during the COVID-19 pandemic. Survey findings indicate that healthcare facilities with worsening teamwork climate had corresponding decreases in other measured domains, including safety climate and healthcare worker well-being. The researchers suggest that healthcare organizations should proactively increase team-based training to reduce patient harm.
Perry AF, Federico F, Huebner J. Boston, MA: Institute for Healthcare Improvement; 2021.
… despite safety concerns . This white paper discusses a 6-item framework to enhance the safety , equity, and … safer methods into telemedicine practice. … Perry AF, FedericoF, Huebner J. Boston, MA: Institute for Healthcare …
De Cassai A, Negro S, Geraldini F, et al. PLoS One. 2021;16:e0257508.
Inattentional blindness occurs when individuals miss an unexpected event due to competing attentional tasks. This study asked anesthesiologists to review the anesthetic management of five simulated cases, one of which included the image of a gorilla in the radiograph, to evaluate inattentional blindness. Only 4.9% of social media respondents reported an abnormality, suggesting that inattentional blindness may be common; the authors suggest several strategies to reduce this error.
Older adults are at increased risk of hospitalization due to COVID-19 infections. This study examined the potential severe drug-drug interactions (DDI) among hospitalized older adults taking two or more medications at admission and discharge. There was a significant increase in prescription of proton pump inhibitors and heparins from admission to discharge. Clinical decision support systems should be used to assess potential DDI with particular attention paid to the risk of bleeding complications linked to heparin-based DDIs.
Sexton JB, Adair KC, Profit J, et al. Jt Comm J Qual Saf. 2021;47:306-312.
… Jt Comm J Qual Saf … Healthcare workers may experience distress … that perceived institutional support was associated with a better safety culture and lower emotional exhaustion, … of support programs . … Sexton JB, Adair KC, Profit J, et al. Perceptions of institutional support for “second …
Demaria J, Valent F, Danielis M, et al. J Nurs Care Qual. 2021;36:202-209.
… J Nurs Care Qual … Little empirical evidence exists assessing … non-handover times were identified. … Demaria J, Valent F, Danielis M, et al. Do falls and other safety issues occur … when nurses are away from patients? Findings from a retrospective study design. J Nurs Care Qual. 2020 Oct 21. …
… Case Objectives … Recognize the role of burnout in a culture of safety. Review the drivers of speaking up in the … the name of patient safety. … The Commentary … by Allan S. Frankel, MD; Kathryn C. Adair, PhD; and J. Bryan Sexton, PhD To assess or improve …
Prior research has shown that numerous factors may impact patient safety in the inpatient psychiatry setting. In this study involving 4371 patients admitted to 14 inpatient psychiatric units at acute care general hospitals, researchers found that older patients and those with longer length of stay were at increased risk for adverse events and medical errors.
Unprofessional and disruptive behavior among health care personnel can adversely impact safety, but reporting and addressing such behavior remains challenging. In this mixed-methods study, researchers identify barriers faculty may face when reporting student lapses in professionalism.
Hannawa AF, Frankel RM. J Patient Saf. 2021;17:e1130-e1137.
… J Patient Saf … J Patient Saf … Effective error disclosure fosters a just culture . In this large study, participants responded to actors as they disclosed a minor error and a sentinel event. When physicians …
Wong AH, Auerbach MA, Ruppel H, et al. Simul Healthc. 2018;13:154-162.
… … Simul Healthc … Workplace violence in health care is a particular area of concern in the emergency department (ED). Patients who are agitated present a unique management challenge for ED providers because they … This mixed-methods study concludes that simulation may be a helpful tool for improving teamwork when caring for …
Wong AH, Ruppel H, Crispino LJ, et al. Jt Comm J Qual Patient Saf. 2018;44:279-292.
… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … The Joint Commission issued a sentinel event alert highlighting workplace violence as a major safety problem. Certain clinical areas such as …