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.
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.
Chang BH, Hsu Y-J, Rosen MA, et al. Am J Med Qual. 2020;35:37-45.
… … Preventing health care–associated infections remains a patient safety priority. This multisite study compared … pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the … in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the …
This systematic review of opioid stewardship practices following surgery identified eight intervention studies intended to reduce postsurgical opioid use. Organizational-level interventions such as changing orders in the electronic health record, demonstrated clear reductions in opioid prescribing. Clinician-facing interventions such as development and dissemination of local guidelines also led to reduced opioid prescribing. The authors emphasize the need for more high-quality evidence on opioid stewardship interventions.
Ban KA, Gibbons MM, Ko CY, et al. Anesth Analg. 2019;128:879-889.
Standardization of care protocols has been shown to improve perioperative outcomes. This article presents the results of an evidence review to develop best practices for perioperative care around colorectal surgery. The authors acknowledge the need for local tailoring in implementing these recommendations.
Rosen MA, Mueller BU, Milstone AM, et al. Jt Comm J Qual Patient Saf. 2017;43:224-231.
This commentary describes the development of a multidisciplinary council to collectively lead patient safety efforts for children's hospitals in a large health system. The authors highlight the value the council brought to project coordination, standard setting, and performance improvement across the organization.
Mathews SC, Demski R, Hooper JE, et al. Acad Med. 2017;92:608-613.
Program infrastructure that incorporates the knowledge of staff at executive and unit levels can enable system improvements to be sustained over time. This commentary describes how an academic medical center integrated departmental needs with overarching organizational concerns to inform safety and quality improvement work. The authors highlight the need for flexibility and structure to ensure success.
Bilimoria KY, Chung JW, Hedges L, et al. New Engl J Med. 2016;374:713-727.
Resident physician duty hour policies have generated rigorous debate, particularly following the most recent ACGME changes implemented in 2011, which shortened maximum shift lengths for interns and increased time off between shifts. This national study cluster-randomized 118 general surgery residency programs to adhere to current ACGME duty hour policies or to abide by more flexible rules that essentially followed the prior standard of a maximum 80-hour work week. Between these two groups, there were no significant differences in patient outcomes, including death and serious complications. Residents reported similar levels of satisfaction with their overall education quality and their well-being. An accompanying editorial notes that the study authors interpret these results as supporting flexible work-hour rules. Alternatively, the editorial author suggests that this study refutes concerns that the new policy compromises patient safety, and as such there is no compelling reason to backtrack on its implementation.
Rosen MA, Goeschel CA, Che X-X, et al. Simul Healthc. 2015;10:372-377.
Simulation has been used to improve patient safety in multiple settings. This study examines how simulation can enhance safety leadership. Executive leaders in health care organizations were given the simulated task of addressing patient safety failures, with the goal of improving participants' competency in transparency and safety culture. Qualitative analysis demonstrated widely diverging participant responses. There was a lack of leadership engagement with frontline staff around safety. Participants cited leadership walk rounds and committee participation as possible leadership involvement mechanisms. The authors also noted that participants did not consistently engage patients 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 changes to improve patient safety.