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 25 Results

Patient and health care professional perspectives on stigma in integrated behavioral health: barriers and recommendations.

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Phelan SM, Salinas M, Pankey T, et al. Ann Fam Med. 2023;21:s56-s60.

Stigma can prevent patients from seeking necessary mental health care. In this study, researchers conducted qualitative interviews with patients and health care providers to assess mental health stigma and barriers to use of integrated behavioral health (IBH) in primary care settings. Participants identified the importance of normalizing discussions about mental health care and patient-centered communication.

Frontiers in measuring structural racism and its health effects.

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Brown TH, Homan PA. Health Serv Res. 2022;57:443-447.

Structural racism, from race-adjusted algorithms to biased machine learning, contributes to and exacerbates health inequities. This commentary calls for developing valid measures of structural racism and a publicly available data infrastructure for researchers. A related study examined the relationship between structural racism and birth outcomes between Black and white patients in Minnesota.

Patient Safety.

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Health Aff (Millwood). 2018;37(11):1723-1908.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.

Creating a comprehensive, unit-based approach to detecting and preventing harm in the neonatal intensive care unit.

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Sedlock EW, Ottosen M, Nether K, et al. J Patient Saf Risk Manag. 2018;23:167–175.

… environments. … Sedlock EW, Ottosen M, Nether K, et al. J Patient Saf Risk Manag. 2018;23:167–175. … EW … M … K … DF … JM … A … N … L … L … R … A … C … A … EJ … Sedlock … Ottosen … Nether … Sittig … Etchegaray … … … Yager … Schafer … Wilkinson … Khan … Arnold … Davidson … Thomas … EW Sedlock … M Ottosen … K Nether … DF Sittig … JM …

Complications.

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Anaesthesia. 2018;73(suppl 1):3-101.

… 1):3-101. … Jones CPL … D … DW … NM … JG … AF … SJ … R … A … FA … CW … J … B … C … SJ … K … DC … GH … J … E … LG … D … C … G … A … … … Lister … Mercer … Patton … Borshoff … Mills … McKinlay … Tyson … Forni … Sellers … Srinivas … Djaiani … Cruikshanks … …

Quality Improvement.

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Gupta M, Kaplan HC, eds. Clin Perinatol. 2017;44(3):469-728.

Improvement efforts in health care focus on quality and patient safety. Articles in this special issue explore the complexities of providing effective perinatal–neonatal care and offer insights regarding alarm fatigue, information technology, teamwork, standardization, and high reliability.

Special Issue: Progress at the Intersection of Patient Safety and Medical Liability.

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Ridgely MS, Greenberg MD, Clancy CM, eds. Health Serv Res. 2016;51(suppl 3):2395-2648.

… Serv Res . 2016;51(suppl 3):2395-2648. … Reyes Nieva H … JB … KA … I … RC … PD … DM … JL … IZ … JF … C … P … MJ … A … EW … SK … EJ … JM … B … AM … MJ … ML … H … SJ … JT … MM … BF … LA … BL … … Firneno … Santos … Ottosen … Aigbe … Sedlock … Bell … Thomas … Etchegaray … Bergstedt … Chappelle … Ottosen … …

Exploring Alternatives To Malpractice Litigation.

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Health Aff (Millwood). 2014;33:6-66.

… as successful strategies. … JM … MJ … L … WM … SK … TH … EJ … A … CK … J … L … P … JK … A … A … M … LM … J … MM … SK … Y … JS … RC … … Etchegaray … Ottosen … Burress … Sage … Bell … Gallagher … Thomas … Hendrich … McCoy … Gale … Sparkman … Santos … …

Predictors of likelihood of speaking up about safety concerns in labour and delivery.

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BMJ Qual Saf. 2011;22.

Silence and poor communication are known threats to patient safety. Despite efforts to promote teamwork and develop shared tools for communication, there are persistent gaps between nurse and physician practices. This study surveyed nurses and physicians working in labor and delivery units and discovered significant differences in their perceptions of patient harm associated with various clinical scenarios. These differences in patient harm ratings were the greatest predictor of speaking up, suggesting that differences in clinical assessment may serve as a useful target for intervention. The authors discuss the negative impact of environments where mental models are not shared, conflict is poorly managed, and disruptive behaviors stifle open communication. A past AHRQ WebM&M commentary discussed a case of "silence" when members of the operating room team were reluctant to speak up to a senior surgeon.

The Gift of Failure: New Approaches to Analyzing and Learning from Events and Near-Misses.

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Fahlbruch B, Carroll JS, eds. Safety Sci. 2011;49(1):1-106

… … B … PH … AR … B … C … M … K … G … D … NG … B … M … KE … EJ … R … PS … PH … OA … OE … J … F … RK … Carroll … Fahlbruch … Lin … Hale … Kirwan … … … Manzey … Leveson … Wahlström … Tamuz … Franchois … Thomas … Ramanujam … Goodman … Lindøe … Engen … Olsen … …

Teaching teamwork during the Neonatal Resuscitation Program: a randomized trial.

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Thomas EJ, Taggart B, Crandell S, et al. Journal of Perinatology. 2007;27.

The investigators found that interns who received teamwork and human error curriculum as part of a resuscitation training program displayed more team behaviors during a resuscitation simulation.

Measuring safety culture in the ambulatory setting: The Safety Attitudes Questionnaire—Ambulatory Version.

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Modak I, Sexton B, Lux TR, et al. J Gen Intern Med. 2007;22:1-5.

While several surveys have been developed to measure the culture of safety in inpatient settings, no outpatient-specific resource yet exists. In this study, funded in part by the Agency for Healthcare Research and Quality (AHRQ), the investigators adapted the Safety Attitudes Questionnaire to address safety culture in the outpatient arena. The resulting 62-item questionnaire was pilot tested in an academic multispecialty practice and was found to reliably identify safety issues. The survey is posted online at the authors' Web site.

Teamwork in the operating room: frontline perspectives among hospitals and operating room personnel.

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Sexton JB; Makary MA; Tersigni AR; Pryor D; Hendrich A; Thomas EJ; Holzmueller CG; Knight AP; Wu Y; Pronovost PJ.

One of the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) 2007 National Patient Safety Goals focuses on the measurement of safety culture. This study evaluated the psychometric properties of a teamwork climate scale (the Safety Attitudes Questionnaire) in the operating room of 60 U.S. hospitals. Their findings support the use of this tool as a method to understand, improve, and evaluate operating room teamwork and design tailored interventions. The authors also provide benchmark data for others who are interested in assessing teamwork climate in their own institutions.

Healthcare: The Problems Are Organizational Not Clinical.

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J Org Behavior. 2006;27(7):809-1029.

… such as how errors are handled in resident education. … J Org Behavior. 2006;27(7):809-1029. … R … DM … AN … DC … N … AL … TJ … H … J … R … MK … KM … MM … T … EJ … IM … AC … AS … MA … JP … JF … CS … M … JA … BJ … J … … … Blatt … Christianson … Sutcliffe … Rosenthal … Tamuz … Thomas … Nembhard … Edmondson … McAlearney … West … Guthrie … …

Teamwork and quality during neonatal care in the delivery room.

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Thomas EJ; Sexton JB; Lasky RE; Helmreich RL; Crandell DS; Tyson J.

The researchers videotaped neonatal resuscitation teams over 1 year to observe their interaction behaviors and compliance with guidelines. They found correlations between team behaviors and compliance with guidelines and overall quality of care.

The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research.

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Sexton JB, Helmreich RL, Neilands TB, et al. BMC Health Serv Res. 2006;6:44.

This AHRQ-supported study discusses one of the best-studied tools to measure and assess patient safety culture. Investigators present the cumulative findings from administering the Safety Attitude Questionnaire (SAQ) to more than 10,000 providers in 203 clinical areas and in 3 countries. The domains that encompass provider attitudes include teamwork climate, safety climate, perceptions of management, job satisfaction, working conditions, and stress recognition. The authors describe their findings with a goal that their tool will allow health care organizations to measure safety attitudes and compare themselves across domains to others. A past study described the results of using such a tool in an academic medical center.

Differentiating close calls from errors: a multidisciplinary perspective.

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Etchegaray JM; Thomas EJ; Geraci JM; Simmons D; Martin SK.

… may, subsequently, be underutilized. … Etchegaray JM; Thomas EJ; Geraci JM; Simmons D; Martin SK. … JM … EJ … JM … D … SK … Etchegaray … Thomas … Geraci … Simmons … …

Implementing and validating a comprehensive unit-based safety program.

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Pronovost P; Weast B; Rosenstein B; et al. J Patient Saf. 2005;1(1):33-40.

The authors implemented a comprehensive unit-based safety program (CUSP) in two intensive care settings. They conclude that the program improved safety culture and decreased length of stay, medication errors, and nursing turnover rates.

The effect of executive walk rounds on nurse safety climate attitudes: a randomized trial of clinical units.

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Thomas EJ, Sexton B, Neilands TB, et al. BMC Health Serv Res. 2005;5:28.

While executive walk rounds (EWRs) vary in application from institution to institution, their use continues to grow as a largely unproven method for improving safety culture. EWRs typically involve a number of executives visiting patient care areas to engage providers and discuss patient safety concerns. This study targeted more than 20 clinical units to determine the impact of EWRs on perceived safety climate using an established survey tool. Results suggested a positive effect on the safety climate attitude of nurses who participated in the rounds. The authors conclude that greater implementation of EWRs may serve as an important tool to improve safety culture and, ultimately, patient safety.

Costs of medical injuries in Utah and Colorado.

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Thomas EJ; Studdert DM; Newhouse JP; Zbar BI; Howard KM; Williams EJ; Brennan TA

… a significant portion of which remain preventable. … Thomas EJ; Studdert DM; Newhouse JP; Zbar BI; Howard KM; Williams EJ; Brennan TA … EJ … DM … JP … BI … KM … EJ … TA … Thomas … …

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