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.
Weiss M, Morrison EW, Szyld D. Front Psychol. 2023;14:1129359.
Psychological safety and willingness to speak up about safety concerns are cornerstone to safety culture. Using four clinical vignettes that described the same case in the Emergency Department but differed with respect to whether a nurse spoke up with treatment-related concerns or remained silent, researchers examined healthcare team members’ perspectives of psychological safety and discussed the importance of organizational and team leadership that encourages and supports speaking up behaviors.
Prior studies have demonstrated rudeness and incivility undermines patient safety. In this study, hospital staff participated in a simulated scenario with scripted, randomly assigned responses to speaking up (civil, pseudo-civil, or rude). Unexpectedly, participants were more likely to speak up following the rude response than either the civil or pseudo-civil responses. The authors describe potential reasons for this unexpected finding.
Kolbe M, Grande B, Lehmann-Willenbrock N, et al. BMJ Qual Saf. 2023;32:160-172.
Debriefing is an effective method for improving individual, team, and system performance, and skilled facilitators can enhance the effectiveness of the debrief. Researchers analyzed 50 video-recorded debrief sessions to assess the interactions between debriefer and participants to identify the type of communication that resulted in increased participant reflection. Advocacy-inquiry prompted increased reflection.
Fridrich A, Imhof A, Staender S, et al. Int J Qual Health Care. 2022;34.
The World Health Organization (WHO) surgical safety checklist (SSC) can improve perioperative outcomes but implementation challenges persist. This study found that peer observation and immediate peer feedback improved SSC compliance and identified primary areas for future efforts to further improve compliance (i.e., reducing interruptions and improving sign outs).
Staender S, Smith A. Curr Opin Anaesthesiol. 2017;30:730-735.
Perioperative management offers opportunities to prevent problems during and after surgery. This review discusses factors that can contribute to surgical complications and recovery challenges. The authors highlight the use of checklists and timely recognition of deteriorating clinical status as strategies for improvement.
Raemer DB, Kolbe M, Minehart RD, et al. Acad Med. 2015;91:530-539.
Speaking up about patient safety concerns remains challenging for health care professionals. This simulation study in the surgical setting found that a workshop on speaking up did not result in more speaking-up behavior, suggesting that changing safety culture requires more intensive interventions.
Staender S. Curr Opin Anaesthesiol. 2015;28:735-9.
Anesthesiology is considered a leader in the patient safety improvement, but this field continues to experience problems due to the complexity of care. This commentary suggests that focusing on resilience and ensuring that actions go as planned (i.e., safety II) can provide continued improvement in patient safety in anesthesia.
Tscholl DW, Weiss M, Kolbe M, et al. Anesth Analg. 2015;121:948-956.
This pre-post study demonstrated increases in teamwork after introduction of an anesthesia checklist. Although evidence for checklists in real-world settings is mixed, this work demonstrates their efficacy as part of an intervention study, which is consistent with prior work.
Mellin-Olsen J, Staender S. Curr Opin Anaesthesiol. 2014;27:630-634.
Examining anesthesia safety in Europe following the recommendations outlined in the 2010 Helsinki Declaration, this review describes how checklists and an implementation toolkit contributed to progress and suggests areas requiring further work to achieve the document's goals.
Wacker J, Staender S. Curr Opin Anaesthesiol. 2014;27:649-656.
Although the anesthesiology field has long been involved in the patient safety movement, errors continue to occur within the specialty. This review summarizes the evidence for strategies to enhance the safety of anesthesia in perioperative care, such as preventing infections and adopting checklists.
Kolbe M, Weiss M, Grote G, et al. BMJ Qual Saf. 2013;22:541-53.
Teamwork training studies have been criticized for not rigorously evaluating participants' skill acquisition and behavior changes. This study reports on the development and validation of a theory-based method for debriefing after teamwork training.
This systematic review outlines the available literature on effective leadership strategies in critical care teams, and describes the factors that influence such behaviors. The authors summarize that effective leaders are critical to team performance and safety, while also providing a research agenda to further investigate these relationships.