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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 - 19 of 19 Results
Godby Vail S, Dierst-Davies R, Kogut D, et al. Jt Comm J Qual Patient Saf. 2023;49:79-88.
Burnout, characterized by emotional exhaustion that results in depersonalization and decreased accomplishment at work, is correlated with poor patient safety culture. Multiple initiatives to measure and reduce healthcare worker burnout have emerged recently. This Department of Defense study used the AHRQ Hospital Survey on Patient Safety Culture to determine the scope of burnout in military hospitals, explore the relationship between burnout and teamwork, and explore effects of teamwork on burnout.
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.
King HB, Kesling K, Birk C, et al. Mil Med. 2017;182:e1612-e1619.
The Partnership for Patients is a government initiative to reduce health care–acquired conditions. This commentary describes a large-scale implementation of the Partnership for Patient methods across the Military Health System. The authors report the results of the program and recommend continuous leadership engagement to achieve success.
Perspective on Safety February 1, 2017
… and Implementation IMPAQ International, LLC … James B. Battles, PhD … Agency for Healthcare Research and Quality (Retired) President Battles Consulting … Heidi B. King, MS … Chief of Patient Safety and High Reliability …
This piece outlines 10 insights about team training in health care learned from experience with the AHRQ-supported teamwork training program, TeamSTEPPS.
Dr. Edmondson is the Novartis Professor of Leadership and Management at Harvard Business School. She is an expert on leadership, teams, and organizational learning. We spoke with her about the role of teamwork in health care and why it is becoming increasingly important.
Hughes A, Gregory ME, Joseph DL, et al. J Appl Psychol. 2016;101:1266-304.
In teamwork training, multidisciplinary health care teams learn to respond effectively to acute situations. Prior studies of team training show improvements in safety culture, but its effect on patient outcomes has been mixed. This meta-analysis of 129 studies found that team training consistently led to enhanced participant satisfaction and skills. These improvements were present across different health care settings and team composition. Investigators also determined that team training positively affects length of stay and mortality, although they caution that few of the primary studies analyzed included these patient outcomes. The authors suggest that team training should be widely implemented and that further studies should evaluate its effect on length of stay, patient satisfaction, and mortality. A PSNet interview discussed how team training from other industries can be applied to health care.
Keebler JR, Dietz AS, Lazzara EH, et al. BMJ Qual Saf. 2014;23:718-26.
This validation study found that the TeamSTEPPS questionnaire—which explores perceptions of teamwork within health care settings—reliably measures how staff perceive leadership, mutual support, situation monitoring, communication, and team structure. According to these findings, this instrument provides a valid way to assess teamwork for safety research and improvement efforts.
Weaver SJ, Rosen MA, DiazGranados D, et al. Jt Comm J Qual Patient Saf. 2010;36:133-42.
Teamwork training programs continue to emerge despite past reviews suggesting their mixed effectiveness in changing behavior. This study conducted a multilevel evaluation of the TeamSTEPPS training program within an operating room service line and used a comparison unit at a separate facility. Following a 4-hour didactic program, the trained group demonstrated increases in the quantity and quality of presurgical procedure briefings and the use of teamwork behaviors observed during cases. Similar to past efforts, increases were also noted in perceptions of safety culture and teamwork attitudes. This study adds to the literature by employing a multilevel evaluation strategy, using a comparison unit, and observing actual behavior change that was attributed to the training. Patient outcomes were not part of the measurement strategy.
Salas E, Klein C, King HB, et al. Jt Comm J Qual Patient Saf. 2008;34:518-527.
This article provides an overview of debriefing as a learning tool in critical incident analysis and in clinical situations such as the operating room. Practical suggestions are provided to enable hospital leadership and team leaders to maximize the utility of debriefing sessions.
Nielsen PE, Goldman MB, Mann S, et al. Obstet Gynecol. 2007;62:294-295.
Crew resource management methods, initially developed in aviation, have been proposed as a means to reduce human errors in medicine through improved teamwork and communication. In this cluster-randomized trial, physicians and nurses on obstetrics wards underwent teamwork training based on the MedTeams model, which has been previously studied in the emergency department. The intervention did not result in improvement in patient (maternal or fetal) clinical outcomes or in the delivery of appropriate process measures. The authors ascribe this negative result to problems noted in other cluster-randomized trials of quality improvement interventions, such as inadequate time to implement the intervention, a relatively short follow-up period, and baseline variation between hospitals in the incidence of adverse events.
Alonso A, Baker DP, Holtzman A, et al. Human Resource Management Review. 2006;16.
This article describes the development of the US Department of Defense's team training program for military health facilities, entitled TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety). The program was based on two prior military crew resource management (CRM) programs and prior evidence in the field and was adapted to address issues encountered in military facilities, including the rapid turnover of personnel and the need to adapt to the cultures of specific military services. The program consists of teaching core skills in leadership, situation monitoring, team support, and communication through an interactive curriculum stressing application to everyday scenarios. The article extensively reviews the challenges of implementing the program and future plans for disseminating and evaluating the training.