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.
Dixon-Woods M, Aveling EL, Campbell A, et al. J Health Serv Res Policy. 2022;27:88-95.
A key aspect of patient safety culture is the perception that all team members should speak up about safety concerns. In this study of 165 frontline and senior leader participants, deciding to report a safety event (referred to as a “voiceable concern”) is influenced by four factors: certainty that something is wrong and is an occasion for voice; system versus conduct concerns, forgivability, and normalization. Organizational culture and context effect whether an incident is considered a voiceable concern.
Wu F, Dixon-Woods M, Aveling E-L, et al. Soc Sci Med. 2021;280:114050.
Reluctance of healthcare team members to speak up about concerns can hinder patient safety. The authors conducted semi-structured interviews with 165 participants (health system leadership, managers, healthcare providers, and staff) about policies, practice, and culture around voicing concerns related to quality and safety. Findings suggest that both formal and informal hierarchies can undermine the ability and desire of individuals to speak up, but that informal organization (such as personal relationships) can motivate and support speaking up behaviors.
Dixon-Woods M, Campbell A, Martin G, et al. Acad Med. 2019;94:579-585.
Disruptive and unprofessional behaviors are known threats to safety culture and contribute to burnout among health professionals. In response to an episode of serious misconduct by a clinician, an academic hospital implemented a structured effort to address disruptive behavior by developing mechanisms for frontline staff to voice their concerns. This article reports on the development and implementation of the effort, which focused on addressing longstanding aspects of institutional culture that were perceived as tolerating—and providing tacit endorsement of—prominent leaders who engaged in disruptive behavior.
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.
Hensley NB, Koch CG, Pronovost P, et al. Jt Comm J Qual Patient Saf. 2019;45:190-198.
Following a sentinel wrong-patient event, a multidisciplinary quality improvement team worked to enhance the safety of blood transfusion. The authors report significant improvement in protocol adherence following institution of barcoding and auditing via the electronic health record.
Rosen MA, DiazGranados D, Dietz AS, et al. Am Psychol. 2018;73:433-450.
Teamwork in health care has been embraced as a key element of patient safety. This review summarizes the evidence regarding teamwork, including strategies to measure team performance and the relationship between teamwork and outcomes.
The patient safety community continues to struggle with implementation and sustainability of improvement programs. This commentary describes how one academic medical center used assessment tools to monitor, measure, and improve safety at the patient, provider, unit, and system levels in the organization.
Martin G, Aveling E-L, Campbell A, et al. BMJ Qual Saf. 2018;27:710-717.
A work environment in which all team members feel comfortable speaking up about safety concerns is a key aspect of positive safety culture. Although formal mechanisms exist within health care institutions for raising safety issues, little is known about how such channels promote or discourage employees from speaking up. Researchers conducted interviews with 165 frontline staff and senior leaders working at three academic hospitals in two countries. They found that leaders viewed formal systems for raising concerns favorably, but other respondents felt uneasy reporting concerns through these channels. Such apprehension occurred especially if the concern was based on a general feeling that something might be wrong rather than hard evidence—what the authors refer to as "soft" intelligence. A PSNet perspective discussed how to change safety culture.
Mathews SC, Pronovost P, Biddison LD, et al. Am J Med Qual. 2018;33:413-419.
Organizational infrastructure is important to ensure sustainability of safety improvements. This commentary describes how one academic medical center integrated structures, processes, and frameworks to build connections within the organization and throughout the community to facilitate success of improvement initiatives.
Pitts SI, Maruthur NM, Luu N-P, et al. Jt Comm J Qual Saf. 2017;43:591-597.
Comprehensive unit-based safety programs have been shown to enhance safety in acute care settings. The investigators adapted this program for a primary care setting and report that safety culture improved following implementation of standard work and safety training. The authors did not report on patient outcomes.
Basu L, Pronovost P, Molello NE, et al. Global Health. 2017;13:64.
The need to improve patient safety is an international concern. This commentary discusses the importance of partnership in reaching the overall goals of global patient safety and highlights experiences in Africa that demonstrate how high-income health care systems can learn from low-income hospitals.
Leslie M, Paradis E, Gropper MA, et al. Health Serv Res. 2017;52:1330-1348.
As implementation of comprehensive health information technology (IT) systems becomes more widespread, concern regarding the unintended consequences of such technologies has increased as well. Usability testing is helpful for optimizing implementation of health IT. Researchers analyzed the impact of health IT use on relationships among clinicians over a year-long period across three academic intensive care units. In the two units with higher health IT use, clinicians were more likely to work in an isolated manner, which was associated with an adverse effect on situational awareness, communication, and patient satisfaction. A previous PSNet perspective discussed some of the pitfalls in the development, implementation, and regulation of health IT and what can be learned to improve patient safety going forward.
Pronovost P, Wu AW, Austin M. JAMA. 2017;318:701-702.
Transparency in the reporting of quality and safety data demonstrates a commitment to improvement, learning, and patient empowerment regarding provider selection. This commentary suggests potential standards for hospitals to adopt for public reporting of their quality data and advocates for an external entity that reports how hospitals adhere to public reporting of quality measures.