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.
Dixon-Woods M, Aveling EL, Campbell A, et al. J Health Serv Res Policy. 2022;27:88-95.
… J Health Serv Res Policy … A key aspect of patient safety culture is the perception that … and senior leader participants, deciding to report a safety event (referred to as a “voiceable concern”) is influenced by four factors: …
Gleason KT, Commodore-Mensah Y, Wu AW, et al. Nurse Educ Today. 2021;104:104984.
… online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in … competence for patient safety among global learners: a prospective cohort study. Nurse Educ …
Dixon-Woods M, Campbell A, Martin G, et al. Acad Med. 2019;94:579-585.
Disruptive and unprofessional behaviors are known threats to safety culture and contribute to burnout among health professionals. In response to an episode of serious misconduct by a clinician, an academic hospital implemented a structured effort to address disruptive behavior by developing mechanisms for frontline staff to voice their concerns. This article reports on the development and implementation of the effort, which focused on addressing longstanding aspects of institutional culture that were perceived as tolerating—and providing tacit endorsement of—prominent leaders who engaged in disruptive behavior.
Hensley NB, Koch CG, Pronovost P, et al. Jt Comm J Qual Patient Saf. 2019;45:190-198.
Following a sentinel wrong-patient event, a multidisciplinary quality improvement team worked to enhance the safety of blood transfusion. The authors report significant improvement in protocol adherence following institution of barcoding and auditing via the electronic health record.
The patient safety community continues to struggle with implementation and sustainability of improvement programs. This commentary describes how one academic medical center used assessment tools to monitor, measure, and improve safety at the patient, provider, unit, and system levels in the organization.
Martin G, Aveling E-L, Campbell A, et al. BMJ Qual Saf. 2018;27:710-717.
… BMJ Qual Saf … BMJ Qual Saf … A work environment in which all team members feel comfortable speaking up about safety concerns is a key aspect of positive safety culture . Although formal … occurred especially if the concern was based on a general feeling that something might be wrong rather than …
Mathews SC, Pronovost P, Biddison LD, et al. Am J Med Qual. 2018;33:413-419.
Organizational infrastructure is important to ensure sustainability of safety improvements. This commentary describes how one academic medical center integrated structures, processes, and frameworks to build connections within the organization and throughout the community to facilitate success of improvement initiatives.
Pitts SI, Maruthur NM, Luu N-P, et al. Jt Comm J Qual Saf. 2017;43:591-597.
Comprehensive unit-based safety programs have been shown to enhance safety in acute care settings. The investigators adapted this program for a primary care setting and report that safety culture improved following implementation of standard work and safety training. The authors did not report on patient outcomes.
Basu L, Pronovost P, Molello NE, et al. Global Health. 2017;13:64.
The need to improve patient safety is an international concern. This commentary discusses the importance of partnership in reaching the overall goals of global patient safety and highlights experiences in Africa that demonstrate how high-income health care systems can learn from low-income hospitals.
Leslie M, Paradis E, Gropper MA, et al. Health Serv Res. 2017;52:1330-1348.
… of health IT use on relationships among clinicians over a year-long period across three academic intensive care … awareness, communication, and patient satisfaction. A previous PSNet perspective discussed some of the pitfalls …
McGinty EE, Thompson DA, Pronovost P, et al. J Nerv Ment Dis. 2017;205:495-501.
Patients with underlying psychiatric conditions may be particularly vulnerable to adverse events. This retrospective study analyzed 790 medical or surgical hospitalizations among adults with serious mental illness in Maryland hospitals over a 10-year period. Numerous patient, provider, and systems factors were correlated with adverse events. The authors suggest that improving safety in patients with mental illness will require multifaceted interventions.
Winner LE, Burroughs TJ, Cady-Reh JA, et al. Jt Comm J Qual Patient Saf. 2017;43:422-428.
Utilizing a systems approach to improvement in health care is important to achieve lasting success. This commentary discusses the use of a tool that blends strategy, project monitoring, and process measurement to inform improvements.
Thornton KC, Schwarz JJ, Gross K, et al. Crit Care Med. 2017;45:1531-1537.
Intensive care units (ICUs) are complex environments that carry high risk for medical errors. This review explores the role of safety culture and patient and family engagement in reducing opportunities for error in ICUs. The authors draw from quality improvement processes to provide insights for implementing safety initiatives and involving patients and families in these efforts.