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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 - 20 of 79 Results
Tawfik DS, Adair KC, Palassof S, et al. Jt Comm J Qual Patient Saf. 2023;49:156-165.
Leadership across all levels of a health system plays an important role in patient safety. In this study, researchers administered the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey to 31 Midwestern hospitals to evaluate how leadership behaviors influenced burnout, safety culture, and engagement. Findings indicate that local leadership behaviors are strongly associated with healthcare worker burnout, safety climate, teamwork climate, workload, and intentions to leave the job.
Sexton JB, Adair KC, Proulx J, et al. JAMA Netw Open. 2022;5:e2232748.
The COVID-19 pandemic increased symptoms of physician burnout, including emotional exhaustion, which can increase patient safety risks. This cross-sectional study examined emotional exhaustion among healthcare workers at two large health care systems in the United States before and during the COVID-19 pandemic. Respondents reported increases in emotional exhaustion in themselves and perceived exhaustion experienced by their colleagues. The researchers found that emotional exhaustion was often clustered in work settings, highlighting the importance of organizational climate and safety culture in mitigating the effects of COVID-19 on healthcare worker well-being.
Adair KC, Heath A, Frye MA, et al. J Patient Saf. 2022;18:513-520.
J Patient Saf. … Psychological safety (PS) is integral to … metric for the ability to speak up in healthcare settings. J Patient Saf. 2022;18(6):513-520. …
Rehder KJ, Adair KC, Eckert E, et al. J Patient Saf. 2023;19:36-41.
Teamwork is an essential component of patient safety.  This cross-sectional study of 50,000 healthcare workers in four large US health systems found that the teamwork climate worsened during the COVID-19 pandemic. Survey findings indicate that healthcare facilities with worsening teamwork climate had corresponding decreases in other measured domains, including safety climate and healthcare worker well-being. The researchers suggest that healthcare organizations should proactively increase team-based training to reduce patient harm.
Klimmeck S, Sexton B, Schwendimann R. Jt Comm J Qual Patient Saf. 2021;47:783-792.
… Jt Comm J Qual Patient Saf … Safety WalkRounds involve health care … climate nine-months after implementation.   … Klimmeck S, Sexton BJ, Schwendimann R. Changes in safety and teamwork … observations to patient safety WalkRounds. Jt Comm J Qual Patient Saf. Epub 2021 Sep 8. …
Haidari E, Main EK, Cui X, et al. J Perinatol. 2021;41:961-969.
High levels of healthcare worker (HCW) burnout may be associated with lower levels of patient safety and quality. In June 2020, three months into the COVID-19 pandemic, 288 maternity and neonatal HCWs were asked about their perspectives on well-being and patient safety. Two-thirds of respondents reported symptoms of burnout and only one-third reported adequate organizational support to meet these challenges. Organizations are encouraged to implement programs to reduce burnout and support HCW well-being.
Rehder KJ, Adair KC, Hadley A, et al. Jt Comm J Qual Saf. 2020;46:18-26.
This study used a brief survey to evaluate disruptive behaviors in one large health system, and its relationship to safety culture. Disruptive behaviors (most commonly bullying and inappropriate discontinuation of communication, such as hanging up the phone) were noted by more than half of individuals surveyed and occurred in nearly all work settings. Greater exposure to disruptive behaviors was associated with poorer teamwork climate, safety climate, and job satisfaction
Tawfik DS, Thomas EJ, Vogus TJ, et al. BMC Health Serv Res. 2019;19:738.
Prior research has found that perceptions about safety climate varies across neonatal intensive care units (NICUs). This large cross-sectional study examining the impact of caregiver perceptions of safety climate on clinical outcomes found that stronger safety climates were associated with lower risk of healthcare-associated infections, but climate did not affect mortality rates.
Sexton J, Schweber N. ProPublica. October 31, 2019.
Misidentification of patients can cause harm. This news investigation explores an unique case of patient misidentification that resulted in unplanned removal of life support and a subsequent death. The authors identify system failures across the broad health care and criminal justice continuum that contributed to the failure.
Johnston BE, Lou-Meda R, Mendez S, et al. BMJ Glob Health. 2019;4.
Medical errors are a concern across the economic spectrum worldwide. This commentary describes an educational effort to develop champions to lead patient safety, quality improvement, and infection control initiatives in health systems in low- and middle-income countries. The authors highlight the importance of contextualizing training to consider local needs and resources.
Profit J, Sharek PJ, Cui X, et al. J Patient Saf. 2020;16:e310-e316.
Prior research has shown that health care worker perceptions of safety culture may vary across different neonatal intensive care units (NICUs). Less is known as to how perceptions of NICU safety culture relate to NICU quality of care. In this cross-sectional study involving 44 NICUs, researchers found a significant relationship between safety climate and teamwork ratings and a lack of health care–associated infections, but no relationship with regard to the other performance metrics examined in the study.

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.
Sexton B, Adair KC, Leonard MW, et al. BMJ Qual Saf. 2018;27:261-270.
Achieving an optimal culture of safety is a central component of patient safety. Prior research supports that higher levels of employee engagement are correlated with improved perceptions of safety culture and that higher rates of burnout are associated with more negative perceptions of safety culture. Leadership WalkRounds has been touted as an intervention to improve safety culture, although the evidence for its efficacy has been mixed. In a more recent study, clinical units that received feedback from walkrounds had lower rates of burnout and more positive perceptions of safety culture. In this cross-sectional survey study, researchers analyzed the relationship between receiving feedback on the actions resulting from walkrounds and health care employees' perceptions of safety culture, engagement, burnout, and work–life balance across 829 settings. Work environments in which walkrounds were conducted with feedback had higher safety culture and employee engagement scores. A past PSNet interview and Annual Perspective discussed the relationship between burnout and patient safety.
Tawfik DS, Sexton JB, Kan P, et al. J Perinatol. 2017;37.
Burnout has been linked to work dissatisfaction and increased rates of adverse events. This retrospective study found that burnout was prevalent among health care workers in the neonatal intensive care unit setting. In high-volume centers, burnout was correlated with higher rates of health care–associated infections. These results demonstrate the association between burnout and care quality.
Profit J, Lee HC, Sharek PJ, et al. BMJ Qual Saf. 2016;25:954-961.
Health care organizations measure safety climate by surveying providers and staff at all levels. Investigators assessed safety culture and teamwork in 44 neonatal intensive care units using two different survey tools—the Safety Attitudes Questionnaire and the Hospital Survey on Patient Safety Culture. They found significant variation in safety and teamwork climate scales of both tools, indicating that the instruments should not be used interchangeably.