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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 - 9 of 9 Results
Cumin D, Skilton C, Weller J. BMJ Qual Saf. 2017;26:209-216.
Standardized tools such as the surgical safety checklist have been implemented in order to improve intraoperative communication between members of the surgical team. However, this simulation study found that much communication about important clinical information took place outside of scheduled formal discussion times, and junior members of the team were more hesitant to speak up about potential patient safety issues.
Torrie J, Cumin D, Sheridan J, et al. BMJ Qual Saf. 2016;25:917-920.
Simulation-based education in health care is common, and typically training exercises use artificial and expired medications instead of actual products. This commentary describes how these fake medications can introduce risks when they are accidentally incorporated into active medication inventory and suggests strategies to reduce such confusion in care environments.
Lee H, Cumin D, Devcich DA, et al. J Adv Nurs. 2015;71:160-8.
This educational experiment randomized nurses to view varying versions of handoff videos. In the recorded handovers, information was transferred either as a simple statement, as spoken information that conveyed concern, as a simple statement with a written summary, or verbally with expressions of concern and a written summary. Researchers found that these factors (expressing concern or referring to a written summary) did not affect information retention, suggesting that other approaches, including standardized communication, may be more useful to improve handoffs.
Boyd M. J Eval Clin Pract. 2015;21:461-9.
Although recommended as a patient safety improvement strategy, the value of root cause analysis has been debated. This commentary suggests a three-step approach for optimizing root cause analysis results to detect factors that contribute to adverse events. The author applies philosophical principles to identify and prioritize interventions to enhance benefit from root cause analysis.
Merry A, Weller J, Mitchell SJ. J Cardiothorac Vasc Anesth. 2014;28:1341-51.
This review explores safety in cardiac surgery and suggests that the anesthesiologist in the surgical team is in the optimal position to maintain an overarching view of the care being provided to a patient, able to ensure that evidence-based practices are followed and appropriate care is delivered.
Boyd M, Cumin D, Lombard B, et al. BMJ Qual Saf. 2014;23:989-93.
Read-backs are widely recommended in order to improve communication of critical clinical information. This simulation study found that anesthesiologists who immediately read back clinical data during simulated emergencies were eight times more likely to retain and use the information appropriately.
Weller J, Boyd M, Cumin D. Postgrad Med J. 2014;90:149-54.
Teamwork in health care has been embraced as a key element of patient safety. This review analyzes the evidence on barriers to building the processes needed to augment teamwork, such as shared mental models and closed-loop communication. The authors outline a seven-step plan to address these barriers using educational, psychological, and organizational methods for improving communication.
Cumin D, Boyd MJ, Webster CS, et al. Simul Healthc. 2013;8:171-9.
Simulations are increasingly used for teamwork training in scenarios ranging from emergency departments to pediatrics. Simulated operating room (OR) scenarios have also been used for studying the effect of surgical checklists in crises. Despite widespread implementation, previous systematic reviews have raised concerns about variation in type and intensity of simulation programs, as well as the paucity of high-quality studies confirming their effectiveness. This review examined simulation training for integrated multidisciplinary OR teams and found that current simulation studies lack standardization of techniques and measurement methods. While participants in these training programs generally felt that they were realistic and useful, significant barriers were noted, including recruitment, fidelity of surgical models, and costs. The authors suggest that future work focus on how best to overcome these barriers.
Gargiulo DA, Sheridan J, Webster CS, et al. BMJ Qual Saf. 2012;21:826-34.
Anesthesiologists were observed to violate sterile technique frequently when administering medications in a simulated setting. These protocol violations could contribute to hospital-acquired infections.