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.
Wolf L, Gorman K, Clark J, et al. J Patient Saf. 2022;18:e1160-e1166.
Human factors play an important role in contributing to and preventing adverse events. This study found that integrating human factors into a new root cause analysis process led to an increase in the number of strong interventions implemented after adverse events.
Unprofessional behavior can hinder patient safety and create a disruptive work environment. Encompassing both qualitative and quantitative literature, this systematic review explored predictors and triggers of incivility in medical teams (defined as disrespectful behaviors but whose intent to harm is ambiguous). The review identified a wide range of triggers of incivility. Studies generally found that incivility occurs mainly within professional disciplines rather than across disciplines (e.g., physician to nurse) and surgery was the most commonly cited uncivil specialty. Situational and cultural triggers for incivility included excessive workload, communication issues, patient safety concerns, lack or support, and poor leadership.
Branzetti JB, Adedipe AA, Gittinger MJ, et al. BMJ Qual Saf. 2017;26:881-891.
… … This randomized study compared simulated performance of a rare, high-risk emergent procedure, transvenous pacemaker placement, with and without a computer-based procedural support tool. The tool included a brief instructional video and a checklist . Trained raters …