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.
Dwyer PE, Watts CD. J Health Life Sci Law. 2020;13):56-67.
… J Health Life Sci Law … Patient safety organizations (PSOs) … given different jurisdictions and entities involved. … Dwyer PE, Watts CD. The benefits and burdens of working with … the Patient Safety and Quality Improvement Act of 2005. J Health Life Sci Law. 2020(13):56-67. …
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.
Dwyer J, Faber-Langendoen K. Acad Med. 2018;93:602-605.
Speaking up about concerns is a cornerstone to safety improvement. This commentary describes a learning exercise developed to prepare students with the skills needed to appropriately and effectively speak up. Participants exhibited improved awareness of when to raise concerns and increased comfort with doing so.
This study used data from a large risk management database to characterize the frequency and type of malpractice claims against pediatric radiologists. Diagnostic error—particularly failure to diagnose congenital and developmental abnormalities—was the most common reason for a malpractice suit, with more than half of claims occurring in the outpatient setting.
Insufficient application of new evidence to inform treatment decisions can hinder safe care delivery. Articles in this special issue explore common renal replacement management strategies that may need to be assessed and redesigned to improve the safety of patients receiving dialysis.
Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790.
… contribute to error in various situations. … Wiklund M, Dwyer A, Davis E. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498705790. … M … A … E … Wiklund … Dwyer … Davis … M Wiklund … A Dwyer … E Davis …
Dietz AS, Pronovost P, Benson KN, et al. BMJ Qual Saf. 2014;23:1031-9.
Teamwork training programs encourage specific behaviors—formally known as behavioral markers—among participants with the goal of improving safety. This systematic review found several methods of measuring behavioral markers, which use inconsistent terminology and have not been adequately validated. The authors suggest that more standardized measurement systems be developed to assess the effectiveness of teamwork training programs.
Arriaga AF, Gawande AA, Raemer D, et al. Ann Surg. 2014;259:403-10.
Simulation training for operating room (OR) teams is an effective tool for improving teamwork and communication, but can be resource intensive and expensive. Due to these barriers, most simulation programs have only included trainees. For this study, a malpractice insurer provided the financial and administrative resources necessary to develop a standardized OR simulation training curriculum that involved active participation of attending surgeons and anesthesiologists. The group provided modest compensation for physicians' time and achieved wide participation. This teamwork curriculum covered principles of communication, assertiveness, and use of the WHO surgical safety checklist. Nearly all (93%) participants thought that the training would help them provide safer care. Dr. David Gaba discussed simulation training in a recent AHRQ WebM&M interview.
Christian CK, Gustafson ML, Roth EM, et al. Surgery. 2006;139:159-173.
This study used a multidisciplinary team of human factors experts and surgeons to identify critical system features that affect patient safety. The observational team carefully followed and recorded events from 10 general surgery cases. Primary findings suggested deficiencies in communication and information flow as well as competing tasks that created poor team performance. The authors suggest this methodology may provide an effective mechanism to identify patient safety issues and potential areas for intervention.
The authors suggest that people management qualities such as teamwork development, performance management, and training should be the primary emphasis during culture change initiatives within hospitals. They argue that better people management leads to, rather than results from, an improved organizational culture.