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.
… gender discrimination and clinical mistakes . … Kans J Med. 2023; June 20 16:153-171. … Jennifer … Paul … Tracy … … … Schroeder … Agarwal … Chernoby … Hein … Anand … Joseph … Rosenstein … Sotto-Santiago … L. … D. … C. … A. … C. … MLR … M. … L. … L. … Jennifer L. Hartwell … …
Rubisch HPK, Blaschke A-L, Berberat PO, et al. Adv Health Sci Educ Theory Pract. 2023;Epub May 11.
Recognizing and learning from mistakes is a core component of medical and nursing education. Based on video recordings of bedside teaching lessons, this study explored how instructors react to and address student mistakes during bedside teaching lessons. Findings highlight the importance of giving purposeful feedback and allowing students the opportunity to recognize and correct their mistakes.
Tawfik DS, Adair KC, Palassof S, et al. Jt Comm J Qual Patient Saf. 2023;49:156-165.
Leadership across all levels of a health system plays an important role in patient safety. In this study, researchers administered the Safety, Communication, Operational, Reliability, and Engagement (SCORE) survey to 31 Midwestern hospitals to evaluate how leadership behaviors influenced burnout, safety culture, and engagement. Findings indicate that local leadership behaviors are strongly associated with healthcare worker burnout, safety climate, teamwork climate, workload, and intentions to leave the job.
Adair KC, Heath A, Frye MA, et al. J Patient Saf. 2022;18:513-520.
… J Patient Saf. … Psychological safety (PS) is integral to … among those exposed to institutional PS programs (i.e., Safety WalkRounds and Positive Leadership WalkRounds ). … … metric for the ability to speak up in healthcare settings. J Patient Saf. 2022;18(6):513-520. …
Rehder KJ, Adair KC, Eckert E, et al. J Patient Saf. 2023;19:36-41.
Teamwork is an essential component of patient safety. This cross-sectional study of 50,000 healthcare workers in four large US health systems found that the teamwork climate worsened during the COVID-19 pandemic. Survey findings indicate that healthcare facilities with worsening teamwork climate had corresponding decreases in other measured domains, including safety climate and healthcare worker well-being. The researchers suggest that healthcare organizations should proactively increase team-based training to reduce patient harm.
The COVID pandemic has increased demand and acceptance of remote care modalities. This commentary suggests that home monitoring is a promising telehealth approach and that its application could improve value while enhancing safety for hospital-at-home and other levels of home-based care patients.
Thibault R, Abbasoglu O, Ioannou E, et al. Clin Nutr. 2021;40:5684-5709.
Mistakes in hospital dietary services can contribute to allergic reactions and patient malnourishment. This guidance shares an improvement approach to care environment food provision that considers clinical concerns and patient limitations as steps toward enhancing patient care.
Klimmeck S, Sexton B, Schwendimann R. Jt Comm J Qual Patient Saf. 2021;47:783-792.
… Jt Comm J Qual Patient Saf … Safety WalkRounds involve health care … climate nine-months after implementation. … Klimmeck S, Sexton BJ, Schwendimann R. Changes in safety and teamwork climate after adding …
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.
Ibrahim SA, Pronovost PJ. JAMA Health Forum. 2021;2:e212430.
Artificial intelligence (AI) and big data have potential to impact health care improvement in a variety of ways. This commentary examines the intersection of AI, diagnosis, and inequality. The authors highlight several innovations that could reduce health disparities and diagnostic errors in at-risk patient populations if adopted.
Morris AH, Stagg B, Lanspa M, et al. J Am Med Inform Assoc. 2021;28:1330-1344.
… J Am Med Inform Assoc … Clinical decision support systems are … clinical care quality and research. … Morris AH, Stagg B, Lanspa M, et al. Enabling a learning healthcare system … produce replicable and personalized clinician actions. J Am Med Inform Assoc. 2021;28(6):1330-1344. …
Wu AW, Vincent CA, Shapiro DW, et al. J Patient Saf Risk Manag. 2021;26:93-96.
The July effect is a phenomenon that presumably results in poor care due to the annual en masse introduction of new doctors into practice. This commentary outlines factors undermining the safe influx of these new clinicians into active, independent practice. The authors discuss how a systemic approach is required to situate these practitioners to provide the safest care possible.
Haidari E, Main EK, Cui X, et al. J Perinatol. 2021;41:961-969.
… J Perinatol … High levels of healthcare worker (HCW) burnout … to reduce burnout and support HCW well-being. … Haidari E, Main EK, Cui X, et al. Maternal and neonatal health care … and patient safety climate amid the COVID-19 pandemic. J Perinatol . 2021;41(5):961-969. …
Sexton JB, Adair KC, Profit J, et al. Jt Comm J Qual Saf. 2021;47:306-312.
… Jt Comm J Qual Saf … Healthcare workers may experience distress … highlighting the importance of support programs . … Sexton JB, Adair KC, Profit J, et al. Perceptions of institutional support for “second …