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.
Dorken Gallastegi A, Mikdad S, Kapoen C, et al. J Surg Res. 2022;274:185-195.
While interoperative deaths (IODs) are rare, they are catastrophic events. This study analyzed five years of data on IODs from a large academic medical center. The authors describe three phenotypes: patients with traumatic injury, those undergoing non-trauma-related emergency surgery, and patients who die during an elective procedure from medical cardiac arrests or vascular injuries. This classification framework can serve as a foundation for future research or quality improvement processes.
Lin D, Peden CJ, Langness SM, et al. Anesth Analg. 2020;131:e155-1159.
The anesthesia community has been a leader in patient safety innovation for over four decades. This conference summary highlights presented content related to the conference theme of “preventing, detecting, and mitigating clinical deterioration in the perioperative period.” The results of a human-centered design analysis exploring tactics to reduce failure to rescue were summarized.
The surgeon–anesthesiologist relationship is crucial to effective teamwork and safe perioperative care. This commentary explores factors that influence the relationship, outlines mental models that affect its effectiveness, suggests research to inform improvement efforts, and provides recommendations to help these two specialists work in tandem to better support safety.
Merrell SB, Gaba DM, Agarwala A, et al. Jt Comm J Qual Patient Saf. 2018;44:477-484.
Emergency manuals have been adopted from high reliability industries as a cognitive aid for guiding interprofessional teams during clinical crises. Investigators interviewed emergency manual users after an intraoperative cardiac arrest and conceptualized how the manual helped provide optimal care. A PSNet interview reviews more broadly how to achieve high reliability in health care.
Weinger MB, Banerjee A, Burden AR, et al. Anesthesiology. 2017;127:475-489.
Simulation training has been increasingly employed in health care, largely due to its success in the aviation industry. Prior research suggests that simulation programs can lead to improved knowledge, skills, and behaviors among health care professionals. In this study, researchers video recorded 263 board-certified anesthesiologists performing two mannequin-based simulated emergencies to determine whether this type of simulation is a reliable way to evaluate competency. Blinded anesthesiologists then evaluated the recordings using standardized rating tools to assess the percentage of critical performance elements carried out and to provide an overall rating of participants' technical and nontechnical skills. In 284 of the simulated emergencies, the participating anesthesiologists completed 81% of the critical performance elements successfully. About 25% of the participants were given low overall ratings. The authors conclude that assessing anesthesiologists' skills in simulated medical emergencies can help identify opportunities for improvement and better inform continuing medical education initiatives. A past PSNet perspective discussed the literature on health care simulation.
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.
Cooper JB, Singer SJ, Hayes J, et al. Simul Healthc. 2011;6:231-8.
Seminal studies and a Joint Commission Sentinel Event Alert have highlighted the importance of engaged leadership in promoting a culture of safety. This study discusses an innovative approach for immersing both clinical and non-clinical management in patient safety through team-based problem solving exercises, where groups of managers were required to respond to a simulated safety threat in real time. Participants found the simulated scenarios to be very effective at illustrating sharp end safety issues and promoting the importance of multidisciplinary teamwork in improving patient safety. A related study also found that formal teamwork training for hospital managers positively impacted safety leadership behaviors.
Singer SJ, Hayes J, Cooper JB, et al. Health Care Manage Rev. 2011;36:188-200.
Active and engaged leadership can improve safety culture and organizational performance on measures of safety and quality. However, prior studies have consistently shown that management has an overly rosy view of safety culture compared to frontline workers, perhaps limiting the ability of managers to improve safety. This study reports on a teamwork training based intervention for a multidisciplinary group of hospital managers. The training emphasized leadership behaviors known to influence safety culture, such as encouraging open discussion of safety issues and errors, and resulted in improved attitudes and use of the targeted leadership behaviors. The importance of leadership in creating a positive safety culture was highlighted in a 2009 Joint Commission Sentinel Event Alert.
… been formed to recommend standard handoff practices (J. Jeffrey Andrews, MD, University of Texas Health Science … explicit and tacit knowledge of the patient. … JeffreyB. Cooper, PhD … Professor of Anaesthesia Harvard Medical School …
Kitch BT, Cooper JB, Zapol WM, et al. Jt Comm J Qual Patient Saf. 2008;34:563-70.
The importance of standardized handoff communications in preventing errors is underscored by its inclusion as a National Patient Safety Goal, and specific guidelines have been developed to promote safe handoff practices. Despite this, multiple studies demonstrate that signout practices are still suboptimal, particularly at academic hospitals. Further corroborating evidence is supplied by this survey of medical and surgical residents at a teaching hospital. The majority of residents reported witnessing patient harm due to inadequate signouts, and signout practices often did not conform to recommended guidelines—specifically, signouts were often conducted over the phone or were subject to frequent interruptions. An AHRQ WebM&M commentary discusses a case of an inadequate signout that resulted in an adverse event.
Cooper JB, Blum RH, Carroll JS, et al. Anesth Analg. 2008;106:574-84, table of contents.
Safety culture measurement is an important part of monitoring and improving safety at the organizational level. Several surveys are used to measure safety, but recent research has demonstrated that safety culture measurements may vary across units within a hospital. Teamwork training, such as crew resource management (CRM), is a method of improving safety culture that is being widely implemented in a variety of clinical settings. In this study, the investigators analyzed safety culture before and after anesthesia staff underwent a CRM training program. Wide variations in overall safety culture perception—and specific dimensions of safety—were found even before clinicians underwent teamwork training, and faculty, nurse anesthetists, and residents had widely differing opinions of the safety climate. The CRM program did not result in sustained improvement in safety climate at any of the participating hospitals. The authors discuss their findings in the context of what is currently known about safety culture measurement, and the implications for designing future teamwork training programs.
… across the landscape. There is action. I have hope. … JeffreyB. Cooper, PhD … Director, Biomedical Engineering, Partners …
My journey into patient safety began in 1972. It was born of serendipity enabled by the good fortune of extraordinary mentors, an environment that supported exploration and allowed for interdisciplinary teamwork, and my own intellectual curiosity. The...
Lucian Leape, MD, is generally known as the father of the modern patient safety movement in the United States. A Harvard professor, Leape shifted his career two decades ago from his clinical practice as a pediatric surgeon to a focus on understanding how medical errors occur and how patient safety can be improved. The result was several groundbreaking studies and commentaries that helped shift the paradigm from "bad people" to "bad systems," and which paved the way for the Institute of Medicine report, "To Err is Human," which he helped write. He has received dozens of honors, including the John M. Eisenberg patient safety award, the duPont Award for Excellence in Children's Health Care, and the Robert Wood Johnson Foundation Investigator's Award in Health Policy Research. He spoke to us about his remarkable career and his thoughts about the patient safety movement.