Skip to main content

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.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Approach to Improving Safety
Displaying 1 - 20 of 73 Results
Tawfik DS, Adair KC, Palassof S, et al. Jt Comm J Qual Patient Saf. 2023;49:156-165.
Leadership across all levels of a health system plays an important role in patient safety. In this study, researchers administered the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey to 31 Midwestern hospitals to evaluate how leadership behaviors influenced burnout, safety culture, and engagement. Findings indicate that local leadership behaviors are strongly associated with healthcare worker burnout, safety climate, teamwork climate, workload, and intentions to leave the job.
Sexton JB, Adair KC, Proulx J, et al. JAMA Netw Open. 2022;5:e2232748.
The COVID-19 pandemic increased symptoms of physician burnout, including emotional exhaustion, which can increase patient safety risks. This cross-sectional study examined emotional exhaustion among healthcare workers at two large health care systems in the United States before and during the COVID-19 pandemic. Respondents reported increases in emotional exhaustion in themselves and perceived exhaustion experienced by their colleagues. The researchers found that emotional exhaustion was often clustered in work settings, highlighting the importance of organizational climate and safety culture in mitigating the effects of COVID-19 on healthcare worker well-being.
Adair KC, Heath A, Frye MA, et al. J Patient Saf. 2022;18:513-520.
Psychological safety (PS) is integral to ensuring healthcare workers feel comfortable asking questions and raising patient safety concerns. A novel PS assessment was administered to over 10,000 healthcare workers and support staff in one academic health system. The scale showed a significant correlation with safety culture, especially among those exposed to institutional PS programs (i.e., Safety WalkRounds and Positive Leadership WalkRounds).
Rehder KJ, Adair KC, Eckert E, et al. J Patient Saf. 2023;19:36-41.
Teamwork is an essential component of patient safety.  This cross-sectional study of 50,000 healthcare workers in four large US health systems found that the teamwork climate worsened during the COVID-19 pandemic. Survey findings indicate that healthcare facilities with worsening teamwork climate had corresponding decreases in other measured domains, including safety climate and healthcare worker well-being. The researchers suggest that healthcare organizations should proactively increase team-based training to reduce patient harm.
Barbash IJ, Davis BS, Yabes JG, et al. Ann Intern Med. 2021;174:927-935.
Starting in 2015, the Centers for Medicare & Medicaid Services has required hospitals to report adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). This study examined sepsis patient encounters at one health system two years before and two years after SEP-1 implementation. Results indicate variable changes in process measures but no improvement in clinical outcomes. The authors suggest revising the measure with more flexible guidelines that allow clinician discretion may improve patient outcomes.
Haidari E, Main EK, Cui X, et al. J Perinatol. 2021;41:961-969.
High levels of healthcare worker (HCW) burnout may be associated with lower levels of patient safety and quality. In June 2020, three months into the COVID-19 pandemic, 288 maternity and neonatal HCWs were asked about their perspectives on well-being and patient safety. Two-thirds of respondents reported symptoms of burnout and only one-third reported adequate organizational support to meet these challenges. Organizations are encouraged to implement programs to reduce burnout and support HCW well-being.
Tawfik DS, Thomas EJ, Vogus TJ, et al. BMC Health Serv Res. 2019;19:738.
Prior research has found that perceptions about safety climate varies across neonatal intensive care units (NICUs). This large cross-sectional study examining the impact of caregiver perceptions of safety climate on clinical outcomes found that stronger safety climates were associated with lower risk of healthcare-associated infections, but climate did not affect mortality rates.
WebM&M Case June 1, 2019
… Case Objectives … Recognize the role of burnout in a culture of safety. Review the drivers of speaking up in the … right side. He was a bit surprised that the effusion wasn't larger given what he had been told by the patient's primary … … by Allan S. Frankel, MD; Kathryn C. Adair, PhD; and J. Bryan Sexton, PhD To assess or improve safety culture in …
Profit J, Sharek PJ, Cui X, et al. J Patient Saf. 2020;16:e310-e316.
Prior research has shown that health care worker perceptions of safety culture may vary across different neonatal intensive care units (NICUs). Less is known as to how perceptions of NICU safety culture relate to NICU quality of care. In this cross-sectional study involving 44 NICUs, researchers found a significant relationship between safety climate and teamwork ratings and a lack of health care–associated infections, but no relationship with regard to the other performance metrics examined in the study.
Schwartz SP, Adair KC, Bae J, et al. BMJ Qual Saf. 2019;28:142-150.
… BMJ Qual Saf … BMJ Qual Saf … Burnout is a highly prevalent patient safety issue. This survey study … work–life balance and burnout. Researchers validated a novel survey measure for work–life balance by asking … the work setting: individuals with different roles within a given setting (such as the intensive care unit, the …
Sexton B, Adair KC, Leonard MW, et al. BMJ Qual Saf. 2018;27:261-270.
… … BMJ Qual Saf … Achieving an optimal culture of safety is a central component of patient safety. Prior research … although the evidence for its efficacy has been mixed. In a more recent study , clinical units that received feedback … the relationship between burnout and patient safety. … Sexton JB, Adair KC, Leonard MW, et al. Providing feedback …
Rhee C, Dantes RB, Epstein L, et al. JAMA. 2017;318:1241-1249.
… at 409 academic, community, and federal hospitals over a 6-year period. They found that the incidence of sepsis … In contrast, analysis of claims-based data suggests a significant increase in the incidence of sepsis over time as well as a marked decrease in sepsis mortality and death or discharge …