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.
Salwei ME, Anders S, Slagle JM, et al. J Patient Saf. 2023;19:e38-e45.
Understanding deviations in care can identify opportunities to improve care delivery and patient safety. This study assessed the incidence and nature of patient- and clinician-reported deviations from optimal care (“non-routine events” or NRE) during ambulatory surgery. The most common type of clinician-reported NRE was process deficiencies, while failures in communication between clinicians and patients or family members was the most common type of patient-reported NRE. Understanding patient perspectives on care deviations can identify opportunities for process improvements and more patient-centered care.
Chrouser KL, Xu J, Hallbeck S, et al. Am J Surg. 2018;216:573-584.
Stressful clinician interactions can diminish the teamwork required to support safe care. This review describes a framework for guiding understanding of how behavioral and emotional responses can affect team behavior, performance, and patient outcomes in the surgical setting. The authors recommend areas of research required to fully understand the phenomenon.
Distractions and interruptions are prevalent in health care delivery. This conference report reviews types of distractions in anesthesiology, their likelihood to introduce significant risks into care processes, and strategies to help manage distractions.
Emphasizing the value of human factors engineering approaches to improving safety in high-risk industries, this commentary outlines tactics, safety issues, interventions, and outcomes of these methods applied in health care. Interventions described included teamwork training, checklists, and safety culture.
Stucky E, Dresselhaus TR, Dollarhide A, et al. Acad Med. 2009;84:251-7.
This study used real-time, self-reported data collection to demonstrate that interns, more so than residents and attendings, experience emotional stress that is associated with sleep quality and patient load.
Cao CGL, Weinger MB, Slagle JM, et al. Hum Factors. 2008;50:276-90.
This study discovered that task performance and mood were different on the night shift compared to daytime hours, a finding the authors attributed to fatigue. They advocate for restructuring of resident schedules to optimize rest in the setting of existing work hour restrictions.
Dollarhide AW, Rutledge T, Weinger MB, et al. J Gen Intern Med. 2008;23:418-22.
Incident reporting systems are ubiquitous, but are limited by low clinician reporting rates and the fact that they identify a relatively small percentage of adverse events. In this feasibility study, a handheld computer-based system for voluntary reporting of medication errors was deployed among physicians and nurses at four academic hospitals. The system demonstrated promise as a supplement to traditional error reporting systems, although even with the increased ease of use, only 16% of clinicians in the study actually reported an error during the study period.
Oken A, Rasmussen MD, Slagle JM, et al. Anesthesiology. 2007;107:909-922.
This study describes the development of an open-ended survey tool administered to anesthesia providers at the conclusion of surgical cases, with the goal of contemporaneously identifying adverse events. The tool identified a broader array of adverse events and near misses than the traditional incident reporting system.
Weinger MB, Ancoli-Israel S. JAMA. 2002;287:955-7.
This review discusses evidence for the role sleep deprivation plays on performance in both laboratory and clinical settings. The authors define sleep deprivation and summarize past research that suggests the impact is greatest on mood and cognitive tasks rather than motor tasks. They also summarize how fatigue can diminish clinical performance and why this factor poses a significant patient safety concern. Implications from their findings call for greater attention to fatigue in clinical settings and the importance of physicians' acknowledging such states as a risk to their patients rather than a sign of personal weakness. Following publication of this review, two studies evaluated the same relationship in anesthesiology residents and medical interns.
Biebuyck J F, Weinger M B, Englund C E. Anesthesiology. 2006;73:995-1021.
This review discusses the important role ergonomic and human factors should play in ensuring safe anesthetic care, drawing on literature from non-health care settings. The authors begin by discussing errors in anesthesia and the opportunities created for such errors by the inevitable nature of the job. They continue by presenting a framework for the contributing factors, which include the work environment (eg, noise, lighting, temperature), the human component (eg, team factors, fatigue, workload), and the equipment and system component (eg, alarms, automation). The authors advocate for greater attention to these contributing factors and further study based on the experiences of other high-risk, error-prone industries.
Howard SK, Gaba DM, Smith B, et al. Anesthesiology. 2003;98:1345-1355.
This study of anesthesiology residents demonstrated that fatigue negatively impairs psychomotor functioning and mood but not measures of clinical performance. Investigators examined, scored, and analyzed the observed behaviors of 12 residents in differing states of prior sleep. The findings support the notion that fatigue can lead to errors as a result of impaired cognitive abilities even if the more difficult to measure clinical performance outcomes were less affected. These findings are the first from a comprehensive simulation study addressing the effects of provider fatigue.
… communication. Based on work in the business arena ( 3 ), Weinger has proposed that effective teamwork in the health … be needed to tackle communication and teamwork errors. … MatthewB. Weinger, MD … Director, Center for Healthcare Simulation …