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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 - 16 of 16 Results
Hansen M, Harrod T, Bahr N, et al. Acad Med. 2022;97:696-703.
Strong physician leadership during clinical crisis can help improve patient outcomes. In this randomized controlled trial, obstetrics-gynecology and emergency medicine residents participated in one of three study arms using high-fidelity mannequins. One study arm received a bespoke leadership curriculum, one received a modified version TeamSTEPPS curriculum, and the third received no leadership training. Participants in both curriculum arms improved leadership scores from “average” before the training to “good” following the training and continuing to six months. The control arm remained unchanged at “average” before and after.
Herzberg S, Hansen M, Schoonover A, et al. BMJ Open. 2019;9:e025314.
Many patient safety strategies focus on effective teamwork among healthcare professionals. This study used a validated instrument, the Clinical Teamwork Scale (CTS), to measure overall teamwork in 44 teams of emergency medical services (EMS) professionals as they responded to 176 simulations of pediatric emergencies. Results indicated that fewer errors were made by teams with higher (better) CTS scores.
Eriksson CO, Ovregaard N, Hansen M, et al. Hosp Pediatr. 2018;8:494-498.
Retrospective chart reviews are important tools for identifying potential adverse events and observing trends. This article describes the validation and streamlining of a chart review tool for pediatric prehospital care. The resulting Pediatric Prehospital Safety Event Detection System (PEDS) took an average of seven minutes to complete and had 87% agreement between expert arbiters.  
Meckler G, Hansen M, Lambert W, et al. Prehosp Emerg Care. 2018;22:290-299.
Few studies have characterized adverse events in emergency medical services (EMS), and even fewer have focused on children. In a chart review of all critically ill pediatric ambulance transports in Multnomah County, Oregon, researchers found that nearly 70% resulted in a patient safety event, 23% of which were severe. The authors call for improved EMS provider training in neonatal care and pediatric resuscitation.
Hansen M, Eriksson C, Skarica B, et al. Am J Emerg Med. 2018;36:380-383.
Adverse events in prehospital care are an increasing area of focus in patient safety. In this retrospective study, researchers examined the medical records of 35 out-of-hospital cardiac arrests among children younger than 18 transported by a single emergency medical services system. They identified a safety issue in 87% of cases and, similar to prior research, they found that medication errors were common.
Guise J-M, Hansen M, O'Brien K, et al. BMJ Open. 2017;7:e014057.
Prehospital emergencies are time critical, and they occur in uncontrolled and often challenging environments. Although emergency medical services (EMS) providers are known to experience high levels of stress, whether their stress contributes to patient safety problems is unclear. In this qualitative study, investigators analyzed perceptions of stress and safety in pediatric out-of-hospital emergencies. They identified factors that contribute to increased stress and therefore adversely affect patient safety, including provider sympathy for children and identification with children or family, which participants felt could cloud their clinical judgment, and lack of familiarity with pediatric emergencies, as seen in other clinical settings. This study highlights a need for specific pediatric training for EMS providers to enhance safety.
Hansen M, Meckler G, Lambert W, et al. BMJ Open. 2016;6:e012259.
Airway management in the prehospital setting can be challenging. Using expert chart review, this retrospective study demonstrated that safety issues associated with pediatric airway management prior to hospital arrival are common, particularly in cases involving cardiac arrest.
Hansen M, Meckler G, OʼBrien K, et al. Pediatr Emerg Care. 2016;32:603-7.
Appropriate airway management is a key component of resuscitation in the prehospital setting. This study surveyed prehospital professionals to understand elements of prehospital pediatric airway management that may contribute to patient safety events. Investigators found that insufficient experience with pediatric airway management and difficulty deciding when an advanced airway should be performed were viewed as highly likely to lead to safety events.
Jones D, Hansen M, Van Otterloo J, et al. Pediatr Emerg Care. 2018;34:862-865.
Emergency medical services may transport patients from the scene of an accident, an outpatient clinic, or a hospital. This study found that rates of adverse events and near misses were higher when pediatric patients came from accident scenes or clinics than if patients were transferred from other hospitals.
Guise J-M, Meckler G, O'Brien K, et al. J Pediatr. 2015;167:1143-8.e1.
Safety problems in prehospital care can lead to adverse events. In this survey study, investigators used the Delphi method to achieve consensus among emergency medical service providers about perceived challenges of caring for children. Respondents reported a need for training, support for clinical assessment and decision-making, appropriate medication and equipment, and skills and experience with caring for children. Multiple prior studies have documented the risk of adverse drug events among pediatric patients. This study suggests that the safety vulnerabilities in pediatric prehospital care are similar to those in other settings and may benefit by adapting interventions that have addressed these issues. A past AHRQ WebM&M commentary examined the complex issues around medication dosing for pediatric patients.
Guise J-M, Segel S. Best Pract Res Clin Obstet Gynaecol. 2008;22:937-51.
This article reviews the history of teamwork training in aviation and in health care and summarizes the evidence behind existing programs. The authors highlight the communication skills taught through teamwork training, the adaptation of crew resource management concepts to health care, and the research that is still needed to fully understand the outcomes associated with such programs.