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.
Handoffs from one care team to another present significant risks to the patient if essential patient information is not shared or understood by all team members. Stakeholders at this children’s hospital developed a structured tool for handoff between surgery and pediatric or neonatal intensive care units. Transfer of information and select patient outcomes improved, handoff time was unchanged, and attendance by all team members increased.
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.
Arshad SA, Ferguson DM, Garcia EI, et al. J Surg Res. 2021;257:455-461.
Engaging patients and families is an important strategy in ensuring safe health care delivery. In this prospective, observational study, use of a parent-centered script did not improve parent engagement during the preinduction checklist and resulted in an expected decline in checklist adherence.
Berman L, Ottosen M, Renaud E, et al. J Pediatr Surg. 2019;54:1872-1877.
Morbidity and mortality (M&M) conferences are designed to review adverse events. They are one method by which physicians undergo peer review to evaluate their performance and can allow health systems to identify potential avenues for improving patient safety. A survey of pediatric surgeons found that while the M&M participation was high, few believed the process results in practice changes or preventing future events. M&Ms considered most effective had a structured approach, were data driven with loop closure, emphasized multidisciplinary participation, and served as an educational forum.
Roybal J, Tsao KJ, Rangel S, et al. Pediatr Qual Saf. 2018;3:e108.
Research has shown that the effectiveness of surgical safety checklists in improving patient outcomes is mixed and may depend in part on implementation as well as providers' attitudes toward the importance of such checklists. In this survey study involving pediatric surgeons, 94% reported using surgical safety checklists but just 55% reported that they perceived such checklists to improve safety.
Anderson KT, Appelbaum R, Bartz-Kurycki MA, et al. Semin Pediatr Surg. 2018;27:92-101.
Clinical skill development in surgery is evolving beyond technical expertise as focus has shifted to how teamwork and human factors affect safety. This commentary describes three key activities associated with surgical safety efforts, including monitoring surgical quality through national data analysis, bundling field-tested processes to prevent surgical site infections, and utilizing surgical checklists.
Hamilton EC, Pham DH, Minzenmayer AN, et al. J Surg Res. 2018;221:336-342.
This study compared direct observation to voluntary reporting for identification of errors and near misses in pediatric surgery. As with prior studies, the team observed underreporting of adverse events and near misses. The authors advocate for systems approaches to enhance reporting.
Putnam LR, Levy SM, Sajid M, et al. Surgery. 2014;156:336-344.
Checklists have improved surgical outcomes in clinical trials and are widely recommended, but a recent observational study showed no change in surgical outcomes following checklist adoption. This study sought to improve adherence to surgical checklists at a single institution. Trained observers assessed checklist performance over three 1-year periods during which various interventions were implemented. The authors report only 30% adherence to the WHO surgical checklist 1 year after adoption. Developing clinician leadership, teamwork training, and stakeholder engagement led to a significant increase in checklist adherence 2 years following implementation. This work underscores the resources and effort needed for successfully implementing safety checklists. In a past AHRQ WebM&M interview, Peter Pronovost discussed utilizing checklists as a tool to improve patient safety.
Levy SM, Senter CE, Hawkins RB, et al. Surgery. 2012;152:331-6.
Poor adherence to individual elements of a surgical safety checklist was noted in this study conducted at a tertiary care children's hospital. The authors attributed this finding to poor implementation and dissemination of the checklist.
Carpenter RO, Austin MT, Tarpley JL, et al. Am J Surg. 2006;191:527-32.
This study surveyed 170 residents across disciplines to understand the role standardized work-hour limitations have played in their daily practices. Investigators discovered that 80% of respondents reported working beyond the restrictions at least once in the past 6 months, and the primary reason for doing so was concern for patient care. Findings also suggested that residents underreport their hours half the time, and differing perceptions of behavior may exist between surgical and non-surgical trainees. Past research exploring the impact of work-hour restrictions includes studies in both the medical and surgical literature.