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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 - 13 of 13 Results
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.
Sherman J, Hedli LC, Kristensen-Cabrera AI, et al. Am J Perinatol. 2020;37:638-646.
This direct observation study examined maternal and neonatal care at 10 labor and delivery units. Investigators uncovered three environmental needs that impact safety: rapid access to blood products, space for neonatal resuscitation, and organization and availability of equipment and supplies. They conclude that applying design thinking to physical space could improve maternal and neonatal safety.
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.
Lyndon A, Malana J, Hedli LC, et al. J Obstet Gynecol Neonatal Nurs. 2018;47:324-332.
A vital component of engaging patients in safety is eliciting their perspective on how they experience both routine care and adverse events. Researchers interviewed women who gave birth in hospitals about what contributed to their sense of safety. Participants emphasized clear communication and empathy as strategies to avoid psychological harm.
Austin N, Goldhaber-Fiebert SN, Daniels K, et al. Anesth Analg. 2016;123:1181-1190.
Most safety improvement interventions in obstetrics do not reflect insights from anesthesia providers. This commentary discusses how one hospital drew from the patient safety expertise of anesthesiologists and used simulation and communication interventions in its labor and delivery unit.
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.
Bennett SC, Finer N, Halamek LP, et al. Jt Comm J Qual Patient Saf. 2016;42:369-76.
Checklists and debriefing improve patient safety across multiple care settings. In this quality improvement initiative, participating hospitals reported high levels of adherence and satisfaction to a protocol for neonatal resuscitation that included a checklist, briefings, and debriefings. The authors advocate for these safety processes to be included in neonatal resuscitation guidelines.
Stone S, Lee HC, Sharek PJ. Jt Comm J Qual Patient Saf. 2016;42:309-315.
This implementation study examined factors that affect sustained improvement associated with an intervention to increase the rate of premature infants receiving breast milk. Investigators found that physician involvement and continuous education contributed to maintaining the intervention. Human factors efforts such as incorporating the intervention into daily workflow and providing feedback also supported this safety practice.
Weinstock P, Halamek LP. Pediatr Clin North Am. 2008;55:1011-24, xi-xii.
Beginning with two brief case histories, this review describes how to apply teamwork skills in pediatrics to improve patient safety.
WebM&M Case December 1, 2005
A resident in the middle of delivering an infant turns away for a moment, during which the mother adjusts herself and the infant drops headfirst onto the floor.
Agarwal S, Swanson S, Murphy A, et al. Pediatrics. 2005;116:e326-e333.
The investigators compared two resuscitation carts during simulated critical incidents to determine which facilitated a quicker and more accurate response.