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.
Gillespie BM, Harbeck EL, Rattray M, et al. Int J Surg. 2021;95:106136.
Surgical site infections (SSI) are a common, yet largely preventable, complication of surgery which can result in increased length of stay and hospital readmission. In this review of 57 studies, the cumulative incidence of SSI was 11% in adult general surgical patients and was associated with increased length of stay (with variation by types of surgery).
Gillespie BM, Harbeck EL, Kang E, et al. J Patient Saf. 2021;17:e448-e454.
Nontechnical skills such as teamwork and communication can influence surgical performance. This Australian hospital implemented a team training program for surgical teams focused on improving individual and shared situational awareness which led to improvements in nontechnical skills.
Wood C, Chaboyer W, Carr P. Int J Nurs Stud. 2019;94:166-178.
Early detection of patient deterioration remains an elusive patient safety target. This scoping review examined how nurses employ early warning scoring systems that prompt them to call rapid response teams. Investigators identified 23 studies for inclusion. Barriers to effective identification and treatment of patient deterioration included difficulty implementing early warning score systems, overreliance on numeric risk scores, and inconsistent activation of rapid response teams based on early warning score results. They recommend that nurses follow scoring algorithms that calculate risk for deterioration while supplementing risk scoring with their clinical judgment from the bedside. A WebM&M commentary highlighted how early recognition of patient deterioration requires not only medical expertise but also collaboration and communication among providers.
… The Commentary … Commentary by Lina Bergman, RN, MSc, and WendyChaboyer, RN, PhD … This transfer from the postanesthesia … Sciences University of Gothenburg Gothenburg, Sweden … WendyChaboyer, RN, PhD … Professor and Deputy Head of School …
Ringdal M, Chaboyer W, Ulin K, et al. BMC Nurs. 2017;16:69.
This qualitative study of hospitalized patients in Sweden found that patients expressed interest in engaging in their care. Themes included shared decision-making and increasing patient understanding of health conditions. Patients also expressed concern about the power dynamic between patients and providers and uncertainty about how to best participate in their own hospital care.
Massey D, Aitken LM, Chaboyer W. Intensive Crit Care Nurs. 2015;31:83-90.
This study of an after-hours rapid response team found that the team was not always activated as intended. More unplanned admissions to intensive care were identified following rapid response implementation, possibly due to enhanced surveillance for clinical deterioration. Under-utilization of rapid response may account for mixed results in improving patient safety.
Gillespie BM, Chaboyer W, Thalib L, et al. Anesthesiology. 2014;120:1380-9.
In contrast to a recent study that showed no change in postoperative morbidity and mortality following checklist adoption, this systematic review explored the evidence and found that checklist implementation was linked to a reduction in overall surgical complications. The authors recommend that checklists be used with other interventions to augment safety.
Gillespie BM, Chaboyer W, Fairweather N. AORN J. 2012;95:576-90.
Interruptions were associated with an increased risk of miscommunication between team personnel during surgical procedures. Teams that had limited experience working together seemed to be particularly vulnerable to miscommunications.
Gillespie BM, Chaboyer W, Fairweather N. BMJ Qual Saf. 2012;21:3-12.
This qualitative study, based on direct observation of 160 surgical procedures, found that communication breakdowns were significantly correlated with deviations from the expected length of the procedure.
Gillespie BM, Chaboyer W, Murray P. AORN J. 2010;92:642-57.
This review analyzed 12 studies focused on team training in surgical settings, and found before-and-after implementation improvements in team practices and complication rates. However, similar to a past review, the authors highlight limitations in study design and the need for additional research on team training strategies.
Bost N, Crilly J, Wallis M, et al. Int Emerg Nurs. 2010;18:210-20.
This review found that handoff errors are common between ambulance personnel and the emergency department, and there is a need for standardization of handoff responsibilities and development of structured handoff protocols.
Gillespie BM, Chaboyer W, Longbottom P, et al. Int J Nurs Stud. 2010;47:732-41.
This qualitative study used interviews with operating room personnel to identify aspects of interpersonal relationships and organizational culture that affect teamwork and communication during surgical procedures.
Chaboyer W, Thalib L, Foster M, et al. Am J Crit Care. 2008;17:255-63; quiz 264.
This study analyzed the most common adverse events following discharge from an intensive care unit and discovered that a respiratory rate of less than 10 breaths/minute or greater than 25 breaths/minute and a heart rate of more than 110 beats/minute were significant independent predictors. Nursing care requirements also predicted adverse events in limited analyses, which the authors suggest is an area for future investigation.