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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 - 19 of 19 Results
Zaheer S, Ginsburg LR, Wong HJ, et al. BMJ Open Qual. 2018;7:e000433.
Establishing a culture of safety within health care organizations requires strong leadership support. This cross-sectional survey study of nurses, allied health professionals, and unit clerks working in the inpatient setting at a single hospital found that positive perceptions of senior leadership support for safety and positive perceptions of teamwork were associated with positive perceptions of patient safety. In addition, when staff perceived senior leadership support for safety to be lacking, the positive impact of direct managerial leadership on staff perceptions of patient safety was more pronounced.
Ginsburg LR, Dhingra-Kumar N, Donaldson LJ. BMJ Open. 2017;7:e016110.
In the United States, patient safety is a required competency within residency training. Despite the dissemination of the WHO Patient Safety Curriculum internationally, little is known about its implementation in low- and middle-income countries. This cross-sectional survey study found that while 30 of 44 countries surveyed were considering implementing a patient safety curriculum, significant barriers to successful implementation persist.
Goldstein DH, Nyce JM, Van Den Kerkhof EG. J Patient Saf. 2017;13:62-68.
This study found differing perceptions of safety culture between clinical (medical and nursing) leadership and organizational (board and administrative) leadership at two Canadian health care organizations. Clinical leadership consistently perceived a weaker safety culture compared to organizational leadership, indicating that organizational leadership may not be aware of frontline workers' concerns. The authors note that this disconnect inhibits development of a high reliability organization.
Ginsburg LR, Oore DG. BMJ Qual Saf. 2016;25:680-7.
Measuring safety culture is essential to patient safety improvement activities. Standardized safety culture surveys, including the Safety Attitudes Questionnaire and the AHRQ Surveys on Patient Safety Culture, are typically reported as numerical scores calculated by aggregating individual responses. This study analyzed safety culture surveys from an accreditation program in a novel manner. Investigators summarized the safety culture level (the averaged ratings of patient safety culture from respondents), culture strength (the consistency of safety ratings among all the members of a department), and culture shape (the distribution of numerical responses). Even among units with identical levels of safety culture, they found that the consistency and distribution of responses revealed different safety climates. One department had high degrees of agreement about safety culture while the other showed divergent perceptions. These two results have different implications for understanding safety culture. The authors advocate for examining agreement and distribution of safety culture survey results as well as mean scores in order to achieve a more comprehensive and actionable understanding of patient safety culture. A past PSNet interview discussed how to measure and change safety culture.
Lukewich J, Edge DS, Tranmer J, et al. Int J Nurs Stud. 2015;52:930-8.
This survey of nursing students found that their comfort with sociocultural aspects of patient safety—such as navigating hierarchies and disclosing adverse events—actually decreased as they gained more clinical experience. These findings suggest a need to address how the practice environment affects nursing students' confidence in patient safety.
Zaheer S, Ginsburg LR, Chuang Y-T, et al. Health Care Manage Rev. 2015;40:13-23.
This survey found that the ease with which errors can be reported is an important driver of frontline staff perception of safety culture at the unit level. A frequent criticism of many voluntary error reporting systems is that they are cumbersome and not straightforward to use.
Tregunno D, Ginsburg LR, Clarke B, et al. BMJ Qual Saf. 2014;23:257-64.
In 2010, patient safety was seen as a critical unmet need in medical and nursing education. Although some formal systems-based curricula have emerged, there remain many areas for improvement related to incorporating these ideals into trainees' practices. This study explored the perspectives of frontline medical, nursing, and pharmacy faculty on integrating patient safety into health professional training. Significant differences emerged between the disciplines: physicians seemed to focus on communication and personal responsibility, pharmacists on the complexity of drugs, and nurses on the care environment. These varied viewpoints colored their approaches to patient safety teaching and suggest that a universal solution is unlikely. External regulatory requirements were seen as effective levers for driving curricular change across fields. The hidden curriculum was once again seen as a major influence on trainees' attitudes and behaviors. These findings highlight the importance of supporting faculty engaged in both formal and informal patient safety teaching.
Ginsburg LR, Chuang Y-T, Berta WB, et al. Health Serv Res. 2010;45:607-632.
The role of organizational leadership in ensuring patient safety has been recognized by accrediting organizations such as The Joint Commission, who issued a sentinel event alert calling attention to the issue and have also developed leadership standards. This Canadian study sought to quantify the relationship between leadership and organizational learning from safety events, and found that hospitals with stronger safety leadership structures demonstrated a greater capacity to learn from errors and near misses. This relationship was particularly true for smaller hospitals. An AHRQ WebM&M perspective discusses how one hospital responded to a never event.
Ginsburg LR, Chuang Y-T, Norton PG, et al. Health Serv Res. 2009;44:2123-47.
Voluntary error reporting systems have many limitations, ranging from selection bias in reporting to a perception that errors may not be appropriately addressed. A 2008 survey found that only a minority of US hospitals had a structured system for following up on reported events. This mixed-methods study used a combination of surveys, focus groups, and expert panels to define measurements for how organizations respond to patient safety events. The authors defined a set of indicators that evaluate the analysis of the event and the dissemination of learnings from the event. Failure to appropriately address reported errors contributes to normalization of deviance, a "culture of low expectations" that has been implicated in high-profile errors.
Ginsburg LR, Norton PG, Casebeer A, et al. Health Serv Res. 2005;40:997-1020.
This study involved design and implementation of a training initiative targeted towards nurses in clinical leadership positions. Investigators enrolled more than 350 nurses to participate in the intervention and compared their perceptions with those of a similar control group. Results suggested improvements in safety culture measures for the study group and an important association with leadership involvement through the process. The authors conclude that training curricula, in conjunction with organizational leadership support for these efforts, can improve patient safety culture.