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.
Gleason KT, Commodore-Mensah Y, Wu AW, et al. Nurse Educ Today. 2021;104:104984.
Massive online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in Healthcare MOOC was delivered in 2013 and 2014. At completion of the course, participants reported increased confidence on all six measured domains (teamwork, communication, managing risk, human environment, recognizing and responding, and culture). At 6 months post-completion, the majority agreed the content was useful and positively influenced their clinical practice, demonstrating that MOOCs are an effective interprofessional learning format.
Pallekonda V, Scholl AT, McKelvey GM, et al. Jt Comm J Qual Patient Saf. 2017;43:611-618.
… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Standardizing handoffs is a recommended strategy to reduce error . This commentary describes a tool developed to support handoffs from the operating room …
Marsteller JA, Wen M, Hsu Y-J, et al. Ann Thorac Surg. 2015;100:2182-9.
… Surg … This study found that cardiac surgical teams had a more positive safety culture (as measured by the AHRQ … teams. Similar to prior studies in which managers reported a more positive safety culture than frontline staff, in this …
Gould LJ, Wachter PA, Aboumatar HJ, et al. Jt Comm J Qual Patient Saf. 2015;41:387-395.
Forming clinical communities that commit to shared goals can augment quality improvement efforts. This commentary describes the development of 14 clinical communities as a way to support institutional quality improvement goals in a large health care system. The authors report the benefits of the program, which enhanced access to expertise and collective knowledge. The article highlights the use of a unit-level engagement model and physician champions as key elements for the success of clinical communities.
Thompson DA, Marsteller JA, Pronovost P, et al. J Patient Saf. 2015;11:143-51.
This study describes a comprehensive approach to identifying safety hazards in a specific clinical environment, the cardiac surgery operating room, which jointly involved experts in organizational science, human factors, and clinical medicine. The authors detail the numerous methods they applied, including surveys, ethnographic direct observation, and analysis of a large database. Safety culture, teamwork and communication, infection prevention, handoffs, failure to adhere to standard practices, and environmental concerns were identified as six key hazards. This type of in-depth, multidisciplinary approach shows promise for determining and prioritizing safety approaches across various health care settings.
Wahr JA, Prager RL, Abernathy JH, et al. Circulation. 2013;128:1139-1169.
This scientific statement from the American Heart Association (AHA) reviews the current state of knowledge on safety issues in the operating room (OR) and provides detailed recommendations for hospitals to implement to improve safety and patient outcomes. These recommendations include using checklists and formal handoff protocols for every procedure, teamwork training and other approaches to enhance safety culture, applying human factors engineering principles to optimize OR design and minimize fatigue, and taking steps to discourage disruptive behavior by clinicians. AHA scientific statements, which are considered the standard of care for cardiac patients, have traditionally focused on clinical issues, but this article (and an earlier statement on medication error prevention) illustrates the critical importance of ensuring safety in this complex group of patients.
Headrick LA, Barton AJ, Ogrinc G, et al. Health Aff (Millwood). 2012;31:2669-2680.
… Health Aff (Millwood) … Health Aff (Millwood) … A seminal 2009 report describes the lack of formal curricula … the institutions encountered many challenges—including a lack of faculty expertise in patient safety—they were able …
Gurses AP, Kim G, Martinez EA, et al. BMJ Qual Saf. 2012;21:810-8.
Failure to address both operational and cultural factors in cardiac surgery has led to serious safety problems and preventable deaths, most notably at the Bristol Royal Infirmary. This study used detailed observation of cardiac surgical procedures by a multidisciplinary team, including clinicians and human factors engineering specialists, to prospectively identify safety hazards. Many types of hazards were identified, including problems with communication and teamwork, poor interoperability of equipment, and failure to follow established safety protocols. The authors make detailed recommendations to guide institutions in addressing these problems.
Hudson DW, Holzmueller CG, Pronovost P, et al. Am J Med Qual. 2012;27:201-9.
To detect and analyze errors, health care has traditionally relied on retrospective methods such as incident reporting and root cause analysis. This commentary draws a contrast between this approach and that used in the nuclear power industry, which focuses on prospective error detection through the use of a robust peer-to-peer assessment process. Nuclear power facilities can request peer review by an independent non-regulatory body, which conducts a detailed safety assessment and makes specific recommendations for safety improvement. The authors recommend developing a similar process for hospitals and discuss barriers that would need to be overcome in order to implement such a process.
Martinez EA, Shore AD, Colantuoni E, et al. Int J Qual Health Care. 2011;23:151-8.
This study found that reducing errors associated with medical devices/equipment in the operating room (OR) was a key opportunity for error prevention, whereas medication safety was a focus for prevention outside the OR.