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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 - 15 of 15 Results
Munoz-Price S, Bowdle A, Johnston L, et al. Infect Control Hosp Epidemiol. 2018:1-17.
This expert guidance provides recommendations to help health care facilities develop policies for preventing health care–associated infections in the operating room. The authors build on existing anesthesia safety practices to outline specific actions for infection prevention and control.
Birnbach DJ, Rosen LF, Fitzpatrick M, et al. The Joint Commission Journal on Quality and Patient Safety. 2017;43.
Communication failures in the operating room are a patient safety issue, and knowing other team members' names may help reduce hierarchies that contribute to errors. Introductions are the first step in the surgical time-out in the World Health Organization Surgical Safety Checklist. However, this study—conducted in the operating rooms of three teaching hospitals—suggests that team members often do not know each other's names and may not view introductions as important for maintaining safety.
Munoz-Price LS, Banach DB, Bearman G, et al. Infect Control Hosp Epidemiol. 2015;36:747-758.
This expert guidance provides recommendations to help hospitals develop policies to reduce the spread of health care–associated infections by individuals visiting patients in isolation. The authors discuss contact precautions and outline specific conditions where these suggestions should be employed.
Arora S, Hull L, Fitzpatrick M, et al. Ann Surg. 2015;261:888-893.
This simulation study examined how residents respond to postoperative deterioration in the surgical ward. Residents improved in validated assessments of clinical performance, teamwork, and communication with patients compared to before the simulation. This work underscores the importance of simulation in patient safety education across multiple clinical settings.
Munoz-Price S, Patel Z, Banks S, et al. Infect Control Hosp Epidemiol. 2014;35:717-20.
Hand hygiene rates remain disappointingly low among physicians and nurses, despite appropriate handwashing being an essential factor in preventing health care–associated infections. In this study, installing a hand sanitizer dispenser on the anesthesia machine resulted in only a limited increase in the frequency of hand sanitization by anesthesiologists.
Bearman G, Bryant K, Leekha S, et al. Infect Control Hosp Epidemiol. 2014;35:107-21.
This guidance examined literature and hospital policies around how health care staff clothing can contribute to health care–associated infections (HAIs). The investigators reveal patients' and health care workers' perceptions regarding clinician attire and recommend research to improve understanding about its potential to spread pathogens.
Bognár A, Barach P, Johnson J, et al. Ann Thorac Surg. 2008;85:1374-81.
In this study, researchers evaluated the culture of safety in pediatric cardiac surgery teams by using a survey based on the Safety Attitudes Questionnaire. Overall, teamwork was rated relatively low, similar to prior research analyzing operating room safety culture.
Nielsen PE, Goldman MB, Mann S, et al. Obstet Gynecol. 2007;62:294-295.
Crew resource management methods, initially developed in aviation, have been proposed as a means to reduce human errors in medicine through improved teamwork and communication. In this cluster-randomized trial, physicians and nurses on obstetrics wards underwent teamwork training based on the MedTeams model, which has been previously studied in the emergency department. The intervention did not result in improvement in patient (maternal or fetal) clinical outcomes or in the delivery of appropriate process measures. The authors ascribe this negative result to problems noted in other cluster-randomized trials of quality improvement interventions, such as inadequate time to implement the intervention, a relatively short follow-up period, and baseline variation between hospitals in the incidence of adverse events.