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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 31 Results
Lusk C, Catchpole K, Neyens DM, et al. Appl Ergon. 2022;104:103831.
Tall Man lettering and color-coding of medication syringes provide visual cues to decrease medication ordering and administration errors. In this study, an icon was added to the standard medication label; participants were asked to identify four medications, with and without the icon, from pre-defined distances. Participants correctly identified the medications with icons slightly more often.
Joseph A, Khoshkenar A, Taaffe KM, et al. BMJ Qual Saf. 2019;28:276-283.
This direct observation study found that minor disruptions in usual workflow can combine to lead to an adverse event. More than half of the observed disruptions were related to the physical layout of the operating room, suggesting that physical design of operating rooms may affect surgical safety.
Schneider A, Wehler M, Weigl M. BMJ Qual Saf. 2019;28:296-304.
Distractions and interruptions have been shown to adversely affect patient safety, but some interruptions may have a positive impact and actually improve care. In this observational study focused on interruptions of doctors and nurses in a single emergency department (ED), researchers found a positive association between interruptions initiated by patients and patient perceptions of ED care quality and efficiency.
Catchpole K, Neyens DM, Abernathy J, et al. BMJ Qual Saf. 2017;26:1015-1021.
Efforts to measure and monitor patient safety improvement can help reveal how work is actually done. This commentary reviews observational study techniques to provide a framework and interactions to consider for researchers seeking to develop observational studies in health care.
WebM&M Case August 1, 2017
Because the plan to biopsy a large gastric mass concerning for malignancy was not conveyed to the hospitalist caring for the patient, she was not made NPO, nor was her anticoagulant medication stopped. The nurse anesthetist performing the preanesthesia checklist noted she received her anticoagulation that morning but did not notify the gastroenterologist. The patient had postprocedural bleeding.
Waterson P, Catchpole K. BMJ Qual Saf. 2016;25:480-4.
Despite the interest in integrating human factors engineering concepts into patient safety improvement strategies, barriers have hindered progress. This commentary explores the evidence around human factors engineering in health care to determine how to enhance the application of these concepts, such as through overlapping attention to work design, performance, and culture.
McCulloch P, Morgan L, New S, et al. Ann Surg. 2015;265.
Safety culture and work systems influence safety, but it is unclear whether safety improvement efforts should focus on one or both factors. This study sought to improve adherence to the WHO surgical safety checklist and to enhance technical and nontechnical team performance using several safety interventions. One intervention focused on improving safety culture, while another was directed at the work system. Investigators also tested a combined approach. Although both team training and system redesign individually demonstrated improvement, the combined approach was more successful than either individual approach. This finding suggests that in order to truly enhance surgical safety, organizations must invest in both systems and culture interventions.
Weigl M, Müller A, Holland S, et al. BMJ Qual Saf. 2016;25:499-508.
Workflow interruptions are often a necessary reality in busy clinical settings, but they can pose serious risks for patient safety. This mixed-method study in a medium-sized community emergency department (ED) found that ED personnels' workflow was disrupted on average 5.6 times per hour and that nearly a third of time was spent on multitasking activities. Similar to a prior study by some of the same authors, interruptions were common and associated with higher perceived workload. In this study, ED professionals' mental workload was negatively related to patients' perceived quality of care and their general satisfaction with their care. However, workflow interruptions were also associated with better patient-related information on discharge and overall quality of transfer, suggesting a more nuanced role for the consequences of interruptions. A prior AHRQ WebM&M perspective discussed interruptions and distractions in health care.
Catchpole K, Russ S. BMJ Qual Saf. 2015;24:545-9.
Checklists, while popularly considered to address safety issues, can be difficult to use reliably. Spotlighting the complexities around designing and implementing checklists to augment health care safety, this commentary relates the differences between medical and aviation checklists to underscore the need to consider sociocultural elements to ensure the success of this safety intervention.
Hignett S, Jones EL, Miller D, et al. BMJ Qual Saf. 2015;24:250-254.
Human factors engineering and quality improvement each offer promising strategies for designing patient safety interventions. This commentary discusses the value of cross-training individuals in elements of both disciplines to encourage integrated research, education, and professional development opportunities.
Morgan L, Pickering S, Hadi M, et al. BMJ Qual Saf. 2015;24:111-9.
An intervention that combined teamwork training with efforts to standardize certain operative procedures resulted in increased adherence to the World Health Organization safe surgery checklist and improved communication within the operating room. No effect was found on clinical outcomes, but the study was likely too small to detect such an impact.
Morgan L, New S, Robertson ER, et al. BMJ Qual Saf. 2015;24:120-7.
Standard operating procedures, or SOPs, are a key tenet of human factors engineering. This time-series analysis found that implementing SOPs in the operating room did not change either surgical process outcomes, such as adherence to the WHO surgical checklist, or clinical outcomes. These results emphasize the challenge of applying systems solutions in clinical settings.
Catchpole K, Ley EJ, Wiegmann D, et al. JAMA Surg. 2014;149:962-8.
Human factors analysis led to five system changes in trauma care: standardizing equipment storage, incorporating medical transport packs, using whiteboards, conducting pretrauma briefings, and performing teamwork training. Implementation of improved processes led to decreased treatment time and length of hospital stay, emphasizing the importance of human factors in enhancing safety and outcomes.
Antoniadis S, Passauer-Baierl S, Baschnegger H, et al. J Surg Res. 2014;188:21-29.
This direct observation study revealed that surgical teams were distracted or interrupted an average of 9.8 times per hour, and these disruptions detracted from interoperative teamwork. Mirroring prior studies, these findings suggest that operating rooms have yet to provide an optimal environment for safe surgery despite efforts to decrease risks.
Robertson ER, Morgan L, Bird S, et al. BMJ Qual Saf. 2014;23:600-7.
Every day the care of hospital patients is handed off from clinician to clinician, creating serious risks for patient safety. The Joint Commission and the Accreditation Council for Graduate Medical Education have called for institutions to implement standardized handoff strategies. However, despite mandates to create safer handoffs, this systematic review found a lack of reliable strategies to improve clinical handoff outcomes. The literature search uncovered 29 relevant handoff studies, only 2 of which were randomized controlled trials. The studies took varied approaches to intervention design and outcome measurement. The quality of most studies was poor, with the majority representing small, uncontrolled, unblinded before-and-after comparisons. The authors of this review call for establishing a common taxonomy to better classify handoffs, improvement methods, and outcomes. Dr. Vineet Arora discussed the challenges of handoffs in a prior AHRQ WebM&M interview.
Hignett S, Carayon P, Buckle P, et al. Ergonomics. 2013;56:1491-503.
This commentary highlights challenges and potential risks around implementing human factors engineering approaches to improve patient safety and recommends areas of research to advance the understanding and reliability of these concepts.
Catchpole K, Gangi A, Blocker RC, et al. J Surg Res. 2013;184:586-91.
Higher acuity trauma patients were more likely to experience disruptions in their care during transitions from the emergency department (ED) to the operating room or intensive care unit. The authors point out that the transition of patients from the ED to other hospital areas is a relatively understudied area of patient safety.