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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 20 Results
Mossburg SE, Weaver SJ, Pillari MS, et al. J Nurs Care Qual. 2019;34:230-235.
High reliability principles from other high-risk industries are frequently adapted to health care to improve safety. In this qualitative study, researchers found that those working on hospital units with better safety performance tended to use language describing responses to safety issues and errors more consistent with high reliability principles than units with lower safety performance.
Paine LA, Holzmueller CG, Elliott R, et al. J Healthc Risk Manag. 2018;38:36-46.
… of the American Society for Healthcare Risk Management … J Healthc Risk Manag … Health care executives and board members have a key role in safety improvement. This article describes the development of a tool and framework to assess the impact leadership …
Mort E, Bruckel J, Donelan K, et al. Am J Med Qual. 2017;32:472-479.
Patient safety approaches often draw from high reliability industries outside of health care. This implementation study described a peer-to-peer assessment program adapted from the nuclear power industry. Two academic medical centers assessed each other's patient safety performance. Each center examined its peer's prevention of central line–associated bloodstream infections (CLABSI), hand hygiene compliance, and overall safety culture as an organization. Peer-to-peer assessments were conducted via site visits, which involved interviews and direct observation. They resulted in rapid practice changes such as dissemination of unit-specific CLABSI rates and central line procedure audits. The process was widely accepted by leaders and frontline staff at both sites. The authors contend that peer-to-peer assessment is feasible and has potential to improve patient safety.
Lee S-H, Phan PH, Dorman T, et al. BMC Health Serv Res. 2016;16:254.
Timely and accurate handoff communication is a critical aspect of patient safety. This survey of hospital staff found that positive perceptions of handoff practices were associated with safety culture, as measured by the AHRQ Hospital Survey on Patient Safety Culture. The authors suggest focusing on improving handoffs as a strategy to enhance safety culture.
Rosen MA, Goeschel CA, Che X-X, et al. Simul Healthc. 2015;10:372-377.
… widely diverging participant responses. There was a lack of leadership engagement with frontline staff around … in their safety strategies. Simulation appears to be a promising leadership education strategy that may uncover gaps in current leadership practices. A PSNet perspective explored how leaders can promote cultural …
Weaver SJ, Lofthus J, Sawyer M, et al. Jt Comm J Qual Patient Saf. 2015;41:147-159.
… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … The … settings. This commentary describes the development of a quality improvement collaborative designed to facilitate the implementation of CUSP in a group of academic and community hospitals. In addition to … science of improving patient safety in a past AHRQ WebM&M interview . …
Weaver SJ, Dy SM, Rosen MA. BMJ Qual Saf. 2014;23:359-72.
This narrative review found substantial evidence that team training can enhance care coordination and patient outcomes, including morbidity and mortality. Bundled interventions had the greatest impact. The authors suggest widespread implementation of team training across health care settings to enhance safety.
Winters BD, Weaver SJ, Pfoh ER, et al. Ann Intern Med. 2013;158:417-25.
Rapid response systems (RRSs) are somewhat effective at preventing cardiorespiratory arrest outside the intensive care unit, according to this AHRQ-funded systematic review published as part of a patient safety supplement in the Annals of Internal Medicine. The review also identifies barriers and facilitators to effective implementation of RRSs in different contexts.
Weaver SJ, Lubomksi LH, Wilson RF, et al. Ann Intern Med. 2013;158:369-74.
This systematic review—part of the AHRQ Making Health Care Safer II report—found some evidence that interventions, such as teamwork training, executive walk rounds, and structured communications approaches, can improve safety culture, especially when bundled together as a multicomponent intervention.
Weaver SJ, Rosen MA, DiazGranados D, et al. Jt Comm J Qual Patient Saf. 2010;36:133-42.
Teamwork training programs continue to emerge despite past reviews suggesting their mixed effectiveness in changing behavior. This study conducted a multilevel evaluation of the TeamSTEPPS training program within an operating room service line and used a comparison unit at a separate facility. Following a 4-hour didactic program, the trained group demonstrated increases in the quantity and quality of presurgical procedure briefings and the use of teamwork behaviors observed during cases. Similar to past efforts, increases were also noted in perceptions of safety culture and teamwork attitudes. This study adds to the literature by employing a multilevel evaluation strategy, using a comparison unit, and observing actual behavior change that was attributed to the training. Patient outcomes were not part of the measurement strategy.