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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 - 20 of 74 Results

Keebler JR, Salas E, Rosen MA, et al. eds. Hum Factors. 2022;64(1):5-258.

… integration, and measures development. … Keebler JR, Salas E, Rosen MA, et al. eds. Hum Factors . … B, Salmon P, Braithwaite J, Clay-Williams R. Catchpole K, Privette A, Roberts L, Alfred M, Carter B, Woltz E, Wilson …
Dekhtyar M, Park YS, Kalinyak J, et al. Diagnosis (Berl). 2022;9:69-76.
Standardized and virtual patient encounters are often used to develop medical and nursing students’ diagnostic reasoning. Through educational interventions including virtual patients, medical students increased their diagnostic accuracy compared to baseline and the completeness and efficiency in the differential diagnosis increased.
Lazzara EH, Salisbury M, Hughes AM, et al. J Patient Saf. 2022;18:e275-e281.
Morbidity and mortality conferences (MMC) serve as a way for health care teams to discuss adverse events and errors with the goal of improving patient safety. This article presents five recommendations to improve MMC: encourage culture change; allocate ample time for open communication to foster innovative thinking; take a global approach; learn from errors and near misses; and do not just talk the talk, but also walk the walk.
Gregory ME, Hughes AM, Benishek LE, et al. J Patient Saf. 2021;17:e47-e70.
High reliability remains an elusive goal for health care organizations. The authors of this study posit that medical teams’ ABCs – attitudes, behaviors, and cognitions – are critical for high-reliability, enhancing team adaptation and increasing patient safety. The article outlines practical tools and educational strategies that can be leveraged by a variety of healthcare organizations to improve team-based care.
Bisbey TM, Kilcullen MP, Thomas EJ, et al. Hum Factors. 2021;63:88-110.
A culture of safety is a key component to successful, sustainable patient safety programs. The authors review existing models of safety culture and propose a framework which synthesizes information across fragmented concepts – including organizational culture, social identity, and social learning – to illustrate the dynamic nature and drivers of safety culture.
Tannenbaum SI, Traylor AM, Thomas EJ, et al. BMJ Qual Saf. 2021;30:59-63.
This article summarizes evidence-based recommendations for team-based patient care during the COVID-19 pandemic. These recommendations focus on team functioning, safety culture, and resilience. The authors discuss how individual-, team-, and organizational-level stressors, as well as work-life stressors, can affect team performance. 
Salas E, Bisbey TM, Traylor AM, et al. Ann Rev Org Psychol Org Behav. 2020;7:283-313.
This review discusses the importance of teamwork in supporting safety, psychological states driving effective safety performance, organizational- and team-level characteristics impacting safety performance, and the role of teams in safety management.
Yamada NK, Catchpole K, Salas E. Semin Perinatol. 2019;43:151174.
Human factors are frequently an important contributing factor to patient safety events. This review describes the role of human factors in patient safety and presents three case studies of human factors affecting care in the NICU. A PSNet Human Factors Primer on human factors expands on these concepts.
Bisbey TM, Reyes DL, Traylor AM, et al. Am Psychol. 2019;74:278-289.
Team development is an important focus of safety improvement. This article provides an overview of team training science and highlights aviation, military, and health care failures that motivated research to understand the psychology of teams. The authors emphasize the importance of multidisciplinary collaboration and the contributions of psychologists as research partners in this work.
Johnston BE, Lou-Meda R, Mendez S, et al. BMJ Glob Health. 2019;4.
Medical errors are a concern across the economic spectrum worldwide. This commentary describes an educational effort to develop champions to lead patient safety, quality improvement, and infection control initiatives in health systems in low- and middle-income countries. The authors highlight the importance of contextualizing training to consider local needs and resources.
Dietz AS, Salas E, Pronovost P, et al. Crit Care Med. 2018;46:1898-1905.
This study aimed to validate a behavioral marker as a measure of teamwork, specifically in the intensive care unit setting. Researchers found that it was difficult to establish interrater reliability for teamwork when observing behaviors and conclude that assessment of teamwork remains complex in the context of patient safety research.

Jt Comm J Qual Patient Saf. 2018;44(7):373-400.

… Saf. 2018;44(7):373-400. … TH … A … M … M … N … S … K … C … B … S … C … H … R … E … Gallagher … Lyren … Coffey … Shepherd … Lashutka … Muething … Frush … Chamness … Olson … Hyde … Nordlund … Phillips … …
Frush K, Chamness C, Olson B, et al. Jt Comm J Qual Patient Saf. 2018;44:389-400.
Improving safety culture is an organizational challenge. This quality improvement study describes a partnership in which a large privately owned group of hospitals, postacute facilities, and outpatient clinics partnered with an academic health system to enhance safety culture and metrics. The program included an assessment of the quality at each site followed by an individual improvement plan. Each site embarked on a multimodal intervention that included leadership engagement, team training, audit and feedback, and traditional quality improvement strategies such as Plan–Do–Study–Act cycles. The authors report significant improvements across measures of patient safety such as health care–associated infections and readmissions.

McDaniel SH, Salas E, eds. Am Psychol. 2018;73:305-600.

… and how context shapes team development. … McDaniel SH, Salas E, eds. Am Psychol. 2018;73:305-600. … Kozlowski SWJ; Zwolski … SG … A … N … JE … E … T … JN … JM … TR … LR … J … R … M … K … SH … GF … N … MR … KL … AL … GC … KJ … EL … SP … SM … KM …
Benjamin L, Frush K, Shaw KN, et al. Ann Emerg Med. 2018;71:e17-e24.
Emergency departments harbor conditions that can hinder safe medication administration for pediatric patients. This policy statement identifies and prioritizes improvements such as implementing kilogram-only weight-based dosing, involving pharmacists in frontline emergency care, and utilizing computerized provider order entry and clinical decision support systems.
Fiscella K, Mauksch L, Bodenheimer T, et al. Jt Comm J Qual Patient Saf. 2017;43:361-368.
Research on teamwork as a key component of safe care delivery has primarily focused on the hospital setting. This commentary highlights six elements that enable development, functionality, and assessment of teamwork in the ambulatory setting.
Marlow SL, Hughes A, Sonesh SC, et al. Jt Comm J Qual Patient Saf. 2017;43:197-204.
This systematic review found that team training programs primarily focus on improving communication among providers, generally involve simulation, and usually assess efficacy with self-report. The authors conclude that team training is improving but remains suboptimal.

J Oncol Pract. 2016;12(11):955-1194.

… JRT; Green JSA; Leib … MP … A … V … SS … SH … AL … KL … E … SJ … L … DL … DJ … ML … RU … HP … D … RS … K … SK … KD … C … E … A … E … C … M … C … D … G … AK … ML … … … Hanley … Chollette … Bruinooge … Taplin … Vogel … Hall … Salas … Weaver … Lederman … Madden … Battle … Smith … …