The PSNet Collection

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.

Effective followership: a standardized algorithm to resolve clinical conflicts and improve teamwork.

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Sculli GL, Fore AM, Sine DM, et al. J Healthc Risk Manag. 2015;35:21-30.

Hierarchy and authority gradients are persistent contributors to poor communication in health care. This commentary describes a way for clinicians to challenge authority and assert themselves to enhance team communication and raise concerns.

Targeted communication intervention using nursing crew resource management principles.

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Tschannen D, McClish D, Aebersold M, et al. J Nurs Care Qual. 2015;30:7-11.

Effective teamwork plays a key role in providing safe patient care. In this study, implementation of a teamwork training intervention based on crew resource management principles improved communication between physicians and nurses on a telemetry unit.

Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information.

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Keenan G, Yakel E, Lopez KD, et al. J Am Med Inform Assoc. 2013;20:245-51.

Direct observation of ward nurses' communication patterns revealed that poor interdisciplinary communication and the lack of a readily accessible care plan overview within the electronic medical record greatly inhibited nurses' situational awareness.

Missed Pneumonia

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WebM&M Case November 1, 2012

A 32-year-old man went to the emergency department with fever and pleuritic chest pain. Following an extensive work-up, he was discharged with "fever, pleural effusion, and chest wall pain", but no clear diagnosis. He returned to the ED 3 days later with worsening pain, continued fever, a new cough, and dyspnea. The patient was started on antibiotics and admitted for pneumonia with effusion.

Do staffing levels predict missed nursing care?

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Kalisch BJ, Tschannen D, Lee KH. Int J Qual Health Care. 2011;23:302-8.

This study surveyed nurses and discovered that inadequate nurse staffing levels may partly explain gaps in required nursing care for patients.

Interruptions and multitasking in nursing care.

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Kalisch BJ, Aebersold M. Jt Comm J Qual Patient Saf. 2010;36:126-132.

This study observed nurses for 4-hour periods and found that interruptions and multitasking were common. Although nurses managed these discontinuities well, the potential for errors is present and should be a target for prevention strategies.

Overcoming barriers to patient safety.

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Kalisch BJ, Aebersold M. Nurs Econ. 2006;24:143-8, 155, 123; quiz 149.

The authors comment on key contributors to errors in an inpatient unit and identify practices that support reliable and safe patient care.

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