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The PSNet Collection: All Content

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.

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Displaying 1 - 20 of 30 Results

Edmondson A. Atria Books, New York, 2023. ISBN: 9781982195069.

Despite the harm that failure can cause, its value as a learning opportunity, if examined through the lens of human error rather than blame, cannot be understated. This book explores how failure that happens in new situations provides new insights toward goal achievement, utilizes knowledge and capitalizes on even small missteps, and can enhance and inform improvement.

Ferrere A, Rider C, Renerte B et al. Sloan Manag Rev. Summer 2022;39-43.

A baseline expectation in a safe organization is that employees feel comfortable and supported when sharing concerns. This article summarizes key results of a large workplace survey to identify cultural elements supporting the psychological safety required to encourage speaking up when ethical or other issues are identified in operations.
Kundu P, Jung OS, Valle LF, et al. Pract Radiat Oncol. 2021;11:e256-e262.
Underreporting of ‘near misses’ can impede efforts to improve healthcare quality and patient safety. Based on hypothetical scenarios involving a patient with a cardiac pacemaker undergoing radiation treatment, this study surveyed healthcare staff about their evaluation of the events and their willingness to report based on their evaluation of the hypothetical scenarios. Findings suggest that cognitive biases can influence willingness to report based on how near miss events are perceived.  
Jung OS, Kundu P, Edmondson AC, et al. Jt Comm J Qual Patient Saf. 2021;47:15-22.
Psychological safety can empower health care workers to communicate concerns and improve care. This survey of radiation oncology staff found that near misses are not processed and reported equally. The odds of reporting near misses and events resulting in harm improved with increased psychological safety. The authors conclude that educating health care workers to identify near misses and fostering psychological safety can increase reporting and improve patient safety.
Berry WR, Edmondson L, Gibbons LR, et al. Health Aff (Millwood). 2018;37:1779-1786.
This study in the Health Affairs patient safety theme issue examines the implementation of surgical safety checklists. Checklists have been shown to improve patient outcomes in randomized control trials, but implementation studies have not consistently demonstrated similar improvements. In this statewide initiative, implementation of the checklist varied significantly among sites. Factors associated with more successful implementation included greater leadership participation, frontline engagement, and more frequent activities for all involved groups, including surgeons, nurses, technicians, and administrators. Sites that invested more funding and time also saw greater checklist implementation. The authors conclude that hospitals that participated more did better. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.
Edmondson AC. Hoboken, NJ: John Wiley & Sons, Inc.; 2019. ISBN: 9781119477266.
Psychological safety is foundational to sharing ideas, reporting errors, and raising concerns. This book provides a framework for leaders to develop psychological safety in their organization. The author argues that it is imperative to facilitate an environment that enables staff to freely exhibit the candor, comfort, and openness needed to sustain high performance and innovation.

Health Aff (Millwood). 2018;37(11):1723-1908.

… … R. … SJ … AA … D. … RM … TP … J. … H. … RT … J. … P. … A. … BZ … M. … J. … D. … M. … D. … G. … M. … M. … A. … H. … C. … K. … D. … T. … EK … W. … J. … AW … R. … TH … MM … WM … … … Jarrín … McHugh … Bates … Singh … Berenson … Berry … Edmondson … Gibbons … Childers … Haynes … Foster … Singer … …
Molina G, Berry WR, Lipsitz S, et al. Ann Surg. 2017;266:658-666.
Establishing a robust culture of safety, in which all staff feel free to voice concerns without fear of reprisal and leadership explicitly prioritizes safety, is crucial to safety improvement efforts. The most successful safety improvement programs have all explicitly prioritized enhancing safety culture. This study reports on the baseline results of a program that sought to improve surgical safety at hospitals in South Carolina. Safety culture was assessed among operating room personnel in 31 hospitals using a validated instrument. The investigators found a relatively robust association between better perceived safety culture and lower 30-day postoperative mortality. Studies in other clinical settings have found similar results. The hospitals involved in this study subsequently participated in a program to implement the Surgical Safety Checklist, which resulted in a significant improvement in mortality among participating hospitals compared to nonparticipating hospitals. A recent PSNet interview with Dr. Mary Dixon-Woods discussed the evolving concept of safety culture.
Haynes AB, Edmondson L, Lipsitz S, et al. Ann Surg. 2017;266:923-929.
Checklists have been shown to reduce surgical morbidity and mortality in randomized trials, but results of implementation in clinical settings have been mixed. This study reports on a voluntary, statewide collaborative program to implement a surgical safety checklist in South Carolina hospitals. Participating sites undertook a multifaceted process to support checklist implementation and culture change. Cross-institutional educational activities were available to all hospitals in the collaborative. Investigators determined that rates of surgical complications declined significantly in hospitals involved in the collaborative compared with those that did not participate, which had no change in postsurgical mortality over the same time frame. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.
Singer SJ, Molina G, Li Z, et al. J Am Coll Surg. 2016;223:568-580.e2.
Although checklists have been shown to improve safety and surgical mortality, they can be difficult to implement, which limits their effectiveness in clinical practice. This study examined whether perceptions of teamwork predicted checklist performance. Trained observers used standardized tools to rate the extent of checklist completion and quality of teamwork. They found that checklists were implemented as intended in only 3% of cases. Surgical teams with better surgeon buy-in to checklists, clinical leadership, communication, and overall teamwork completed more checklist components. Clinical factors, including older patient age and longer duration of surgery, were also associated with performing more of the checklist. The authors suggest that teamwork is critical to checklist implementation. A PSNet interview discussed the challenges of implementing checklists in health care.
Edmondson AC, Higgins M, Singer SJ, et al. Res Hum Dev. 2016;13:65-83.
Ensuring that workers feel comfortable raising concerns in an organization is crucial to facilitating learning from failures. Exploring how psychological safety influences staff communication about problems in education and health care, this commentary describes similar challenges in both settings associated with hierarchy, leadership, and professional roles. The authors outline areas of research needed to understand ways to improve transparency in each environment.
Singer SJ, Jiang W, Huang LC, et al. Med Care Res Rev. 2015;72:298-323.
In this survey of surgical teams at South Carolina hospitals that were implementing the World Health Organization's surgical safety checklist, the majority of overall responses about patient safety were positive. However, there was wide variation between hospitals. In some hospitals surveyed, up to 57% of respondents reported that they would not feel safe being treated in their own operating room.
Huang LC, Conley D, Lipsitz S, et al. BMJ Qual Saf. 2014;23:639-50.
The effectiveness of safety checklists depends mostly on how well they are implemented and performed—a recent study found no improvements in surgical outcomes with their adoption. This study created reliable observation tools for measuring surgical safety checklist performance and teamwork in the operating room.
Edmondson A. Harv Bus Rev. 2011;89:48-55, 137.
… as health care. The ability to learn from failures is a crucial characteristic of high reliability organizations , and creating a climate that emphasizes organizational learning is an … essential element of safety culture . This article draws a distinction between preventable failures in predictable …

Harv Bus Rev. April 2011;89(4);1-140.  

…   … Tinsley CH, Dillon RL; Seligman MEP … A. … AC … MH … AE … F. … GP … RG … AG … PM … D. … L. … A. … … … J. … B. … R. … S. … T. … D. … R. … F. … P. … Ignatius … Edmondson … Bazerman … Tenbrunsel … Gino … Pisano … McGrath … … … Silverman … Gervais … Trompenaars … Woolliams … G. … C. … M. … A. Ignatius … AC Edmondson … MH Bazerman … AE …