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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 44 Results
Stierman EK, O'Brien BT, Stagg J, et al. Qual Manag Health Care. 2023;32:177-188.
Maternal morbidity and mortality remain a significant problem in U.S. health care. This article describes Texas and Oklahoma’s adoption of a perinatal quality improvement initiative, including the implementation of the Alliance for Innovation of Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units. Findings suggest that adoption of initiative components varies across obstetric units; the majority of units had standardized processes for serious events (obstetric hemorrhage, massive transfusion, severe hypertension) but fewer units offered regular training on effective teamwork and communication for their staff.
Godby Vail S, Dierst-Davies R, Kogut D, et al. Jt Comm J Qual Patient Saf. 2023;49:79-88.
Burnout, characterized by emotional exhaustion that results in depersonalization and decreased accomplishment at work, is correlated with poor patient safety culture. Multiple initiatives to measure and reduce healthcare worker burnout have emerged recently. This Department of Defense study used the AHRQ Hospital Survey on Patient Safety Culture to determine the scope of burnout in military hospitals, explore the relationship between burnout and teamwork, and explore effects of teamwork on burnout.
Benishek LE, Kachalia A, Daugherty Biddison L. JAMA. 2023;329:1149-1150.
The quality and culture of the health care work environment is known to affect care delivery. This commentary discusses human-centered and participatory design approaches as avenues for developing improvements in clinician well-being that will enhance safety for staff, providers, and patients.
Gregory ME, Hughes AM, Benishek LE, et al. J Patient Saf. 2021;17:e47-e70.
High reliability remains an elusive goal for health care organizations. The authors of this study posit that medical teams’ ABCs – attitudes, behaviors, and cognitions – are critical for high-reliability, enhancing team adaptation and increasing patient safety. The article outlines practical tools and educational strategies that can be leveraged by a variety of healthcare organizations to improve team-based care.
Bisbey TM, Kilcullen MP, Thomas EJ, et al. Hum Factors. 2021;63:88-110.
A culture of safety is a key component to successful, sustainable patient safety programs. The authors review existing models of safety culture and propose a framework which synthesizes information across fragmented concepts – including organizational culture, social identity, and social learning – to illustrate the dynamic nature and drivers of safety culture.
Tannenbaum SI, Traylor AM, Thomas EJ, et al. BMJ Qual Saf. 2021;30:59-63.
This article summarizes evidence-based recommendations for team-based patient care during the COVID-19 pandemic. These recommendations focus on team functioning, safety culture, and resilience. The authors discuss how individual-, team-, and organizational-level stressors, as well as work-life stressors, can affect team performance. 
Salas E, Bisbey TM, Traylor AM, et al. Ann Rev Org Psychol Org Behav. 2020;7:283-313.
This review discusses the importance of teamwork in supporting safety, psychological states driving effective safety performance, organizational- and team-level characteristics impacting safety performance, and the role of teams in safety management.
Yamada NK, Catchpole K, Salas E. Semin Perinatol. 2019;43:151174.
Human factors are frequently an important contributing factor to patient safety events. This review describes the role of human factors in patient safety and presents three case studies of human factors affecting care in the NICU. A PSNet Human Factors Primer on human factors expands on these concepts.
Bisbey TM, Reyes DL, Traylor AM, et al. Am Psychol. 2019;74:278-289.
Team development is an important focus of safety improvement. This article provides an overview of team training science and highlights aviation, military, and health care failures that motivated research to understand the psychology of teams. The authors emphasize the importance of multidisciplinary collaboration and the contributions of psychologists as research partners in this work.
Dietz AS, Salas E, Pronovost P, et al. Crit Care Med. 2018;46:1898-1905.
This study aimed to validate a behavioral marker as a measure of teamwork, specifically in the intensive care unit setting. Researchers found that it was difficult to establish interrater reliability for teamwork when observing behaviors and conclude that assessment of teamwork remains complex in the context of patient safety research.
Arbaje AI, Hughes A, Werner N, et al. BMJ Qual Saf. 2019;28:111-120.
Patients are at risk for adverse events after they transition from hospital to home. This direct observation and interview study identified significant concerns related to care transitions from hospital to home health care among patients discharged from the hospital. The study team found instances of missing and erroneous information. Information also had to be gleaned from multiple sources, and too much information could cause confusion and interfere with home health care. The authors recommend redesigning the care transition process from hospital to home health care providers in order to promote safety.
Stoklosa H, Scannell M, Ma Z, et al. Emerg Med J. 2018;35:406-411.
Emergency department crowding is linked to medication errors and other preventable harm. Crowding requires providers to evaluate patients quickly under suboptimal conditions, such as in hallways or waiting rooms with inadequate nursing support, which may lead to diagnostic errors. This cross-sectional survey of emergency medicine physicians assessed how evaluating patients in the hallway or with a companion present changed their usual diagnostic practices. Researchers found that 90% of physicians altered their history-taking or physical examination, and 40% reported a diagnostic error or delay as a result. The most common missed diagnoses were suicidal ideation, abuse or neglect, and genitourinary system disease. A PSNet Perspective and a WebM&M commentary discussed strategies to reduce diagnostic errors in emergency departments.
Gregory ME, Russo E, Singh H. Appl Clin Inform. 2017;8:686-697.
Electronic health record (EHR) alerts are a major source of alert fatigue among providers. This study suggests that EHR alerts and workload may contribute to primary care provider burnout. The authors conclude that both individual and organizational level interventions are necessary to address workload related to EHR alerts.
Fiscella K, Mauksch L, Bodenheimer T, et al. Jt Comm J Qual Patient Saf. 2017;43:361-368.
Research on teamwork as a key component of safe care delivery has primarily focused on the hospital setting. This commentary highlights six elements that enable development, functionality, and assessment of teamwork in the ambulatory setting.
King HB, Kesling K, Birk C, et al. Mil Med. 2017;182:e1612-e1619.
The Partnership for Patients is a government initiative to reduce health care–acquired conditions. This commentary describes a large-scale implementation of the Partnership for Patient methods across the Military Health System. The authors report the results of the program and recommend continuous leadership engagement to achieve success.
Marlow SL, Hughes A, Sonesh SC, et al. Jt Comm J Qual Patient Saf. 2017;43:197-204.
This systematic review found that team training programs primarily focus on improving communication among providers, generally involve simulation, and usually assess efficacy with self-report. The authors conclude that team training is improving but remains suboptimal.
Perspective on Safety February 1, 2017
… of Defense … References … 1. Baker DP, Gustafson S, Salas E, Barach P, Battles JB, King H. The relation between … AHRQ Publication Nos. 080034 (1-4). [Available at] 3. Hughes AM, Gregory ME, Joseph DL, et al. Saving lives: a meta-analysis …
This piece outlines 10 insights about team training in health care learned from experience with the AHRQ-supported teamwork training program, TeamSTEPPS.
Dr. Edmondson is the Novartis Professor of Leadership and Management at Harvard Business School. She is an expert on leadership, teams, and organizational learning. We spoke with her about the role of teamwork in health care and why it is becoming increasingly important.