Skip to main content

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.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Displaying 1 - 18 of 18 Results
Keebler JR, Lynch I, Ngo F, et al. Jt Comm J Qual Patient Saf. 2023;49:373-383.
Handoffs are an inevitable part of hospital care; clear communication between providers is required to ensure safe care. This quality improvement project aimed to improve handoffs between the cardiovascular (CV) operating room and CV intensive care unit by developing, implementing, and sustaining a structured handoff bundle. A participatory design was used to ensure that the tool contained only the key elements to support implementation without overburdening users.
Rogers JE, Hilgers TR, Keebler JR, et al. Jt Comm J Qual Patient Saf. 2022;48:612-616.
Patient safety investigations hinge on the expertise and experiences of the investigator. This commentary discusses the ways in which cognitive biases can impact patient safety investigations and identifies potential mitigation strategies to improve decision-making processes.
Webster KLW, Keebler JR, Lazzara EH, et al. Jt Comm Qual Patient Saf. 2022;48:343-353.
Effective handoff communication is a key indicator of safe patient care. These authors outline a new model for handoff communication, integrating three theoretical frameworks addressing relevant inputs (i.e., individual organizational, environmental factors), mediators (e.g., communication, leadership), outcomes (e.g., patient, provider, teamwork, and organizational outcomes), and adaptation loops.
Doorey AJ, Turi ZG, Lazzara EH, et al. Catheter Cardiovasc Interv. 2022;99:1953-1962.
Closed loop communication (CLC) ensures a clear transfer of information by having the recipient repeat the order for verification.  In this study, procedures in the cardiac catheterization lab were observed to assess the frequency and accuracy of CLC. Despite three interventions over five years (education, on-going feedback, accountability), CLC remained suboptimal, with both incomplete orders given and incomplete responses.
Lazzara EH, Simonson RJ, Gisick LM, et al. Ergonomics. 2022;65:1138-1153.
Structured handoffs support appropriate communication between teams or departments when transferring responsibility for care. This meta-analysis aimed to determine if structured, standardized post-operative anesthesia handoffs improved provider, patient, organizational and handoff outcomes. Postoperative outcomes moved in a generally positive direction when compared with non-standardized handoffs. The authors suggest additional research into pre- and intra-operative handoffs is needed.
Lazzara EH, Salisbury M, Hughes AM, et al. J Patient Saf. 2022;18:e275-e281.
Morbidity and mortality conferences (MMC) serve as a way for health care teams to discuss adverse events and errors with the goal of improving patient safety. This article presents five recommendations to improve MMC: encourage culture change; allocate ample time for open communication to foster innovative thinking; take a global approach; learn from errors and near misses; and do not just talk the talk, but also walk the walk.
Webster KLW, Stikes R, Bunnell L, et al. J Perinat Neonatal Nurs. 2021;35:258-265.
Infant misidentification or abduction are considered never events. This article discusses the results of a failure mode and effects analysis to identify and eliminate or reduce the risk of infant misidentification or abduction. Twenty-eight failure modes were identified; the highest-ranked items involved concerns for uninvited individuals on the unit, interactions with child-protective services, alarm fatigue, and inadequate identification checks of the infants with mothers.
Gregory ME, Hughes AM, Benishek LE, et al. J Patient Saf. 2021;17:e47-e70.
High reliability remains an elusive goal for health care organizations. The authors of this study posit that medical teams’ ABCs – attitudes, behaviors, and cognitions – are critical for high-reliability, enhancing team adaptation and increasing patient safety. The article outlines practical tools and educational strategies that can be leveraged by a variety of healthcare organizations to improve team-based care.
Misasi P, Keebler JR. Ther Adv Drug Saf. 2019;10:2042098618821916.
This pre–post study reports a decline in medication error rates in prehospital emergency services following implementation of a human factors engineering approach. The providers implemented a team-based cross-check process using standardized communication for high-risk medications and found a significant reduction in medication errors.
Guttman OT, Lazzara EH, Keebler JR, et al. J Patient Saf. 2021;17:e1465-e1471.
Communication errors in health care are a persistent challenge to patient safety. This commentary advocates for studying behavioral, cognitive, linguistic, environmental, and technological factors to help understand barriers to effective information exchange in health care. The authors suggest that approaches targeting each set of barriers be developed and embedded into learning activities to generate lasting improvements.
Keebler JR, Lazzara EH, Patzer BS, et al. Hum Factors. 2016;58:1187-1205.
This meta-analysis of handoff protocols found that standardizing handoffs has led to improvements in amount of information passed on, patient outcomes, and provider satisfaction. Although the authors caution that structured handoffs can take longer than usual handoff practices and that errors of omission can persist, they conclude that handoff protocols enhance patient safety across multiple care settings.
Lyons R, Lazzara EH, Benishek LE, et al. Jt Comm J Qual Patient Saf. 2015;41:115-125.
Updating an earlier article that revealed a set of generalizable debriefing strategies, this commentary describes 13 best practices for enhancing the effectiveness of team debriefings in medical simulations. Organized in three categories consisting of preparation, facilitator responsibilities during the session, and considerations for the content discussed, the authors outline recommendations to augment learning and team performance related to debriefings.
Keebler JR, Dietz AS, Lazzara EH, et al. BMJ Qual Saf. 2014;23:718-26.
This validation study found that the TeamSTEPPS questionnaire—which explores perceptions of teamwork within health care settings—reliably measures how staff perceive leadership, mutual support, situation monitoring, communication, and team structure. According to these findings, this instrument provides a valid way to assess teamwork for safety research and improvement efforts.
Lazzara EH, Benishek LE, Dietz AS, et al. Jt Comm J Qual Patient Saf. 2014;40:21-29.
This commentary outlines key factors to consider when designing simulation initiatives to enhance human performance in health care. The authors also provide examples of hospitals that have implemented approaches incorporating science, staff, supplies, space, support, systems, success, and sustainability in simulation-based training.
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.
Weaver SJ, Rosen MA, DiazGranados D, et al. Jt Comm J Qual Patient Saf. 2010;36:133-42.
Teamwork training programs continue to emerge despite past reviews suggesting their mixed effectiveness in changing behavior. This study conducted a multilevel evaluation of the TeamSTEPPS training program within an operating room service line and used a comparison unit at a separate facility. Following a 4-hour didactic program, the trained group demonstrated increases in the quantity and quality of presurgical procedure briefings and the use of teamwork behaviors observed during cases. Similar to past efforts, increases were also noted in perceptions of safety culture and teamwork attitudes. This study adds to the literature by employing a multilevel evaluation strategy, using a comparison unit, and observing actual behavior change that was attributed to the training. Patient outcomes were not part of the measurement strategy.