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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 - 20 of 70 Results
Choi JJ, Rosen MA, Shapiro MF, et al. Diagnosis (Berl). 2023;Epub Aug 11.
Teamwork is increasingly seen as an important component of diagnostic excellence. Through a systematic review and observations of team dynamics in a hospital medical ward, researchers identified three areas requiring additional research- (1) team structure, (2) contextual factors, and (3) emergent states (e.g., shared mental models).
Godby Vail S, Dierst-Davies R, Kogut D, et al. Jt Comm J Qual Patient Saf. 2023;49:79-88.
… Jt Comm J Qual Patient Saf … Burnout , characterized by emotional … of Defense Patient Safety Culture Survey. Jt Comm J Qual Patient Saf. 2023;49(2):79-88 10.1016/j.jcjq.2022.11.004 …
Webster KLW, Keebler JR, Lazzara EH, et al. Jt Comm Qual Patient Saf. 2022;48:343-353.
… Comm Qual Patient Saf … Effective handoff communication is a key indicator of safe patient care. These authors outline a … and adaptation loops. … Webster KLW, Keebler JR, Lazzara EH, et al. Handoffs and teamwork: a framework for … Comm Qual Patient Saf. 2022;48(6-7):343-353. doi: 10.1016/j.jcjq.2022.04.001 …
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.
Gregory ME, Hughes AM, Benishek LE, et al. J Patient Saf. 2021;17:e47-e70.
J Patient Saf … High reliability remains an elusive goal for … tools and educational strategies that can be leveraged by a variety of healthcare organizations to improve team-based … perfect medical team: critical components for adaptation. J Patient Saf. 2021;17(2):e47-e70. …
Tannenbaum SI, Traylor AM, Thomas EJ, et al. BMJ Qual Saf. 2021;30:59-63.
This article summarizes evidence-based recommendations for team-based patient care during the COVID-19 pandemic. These recommendations focus on team functioning, safety culture, and resilience. The authors discuss how individual-, team-, and organizational-level stressors, as well as work-life stressors, can affect team performance. 
Salas E, Bisbey TM, Traylor AM, et al. Ann Rev Org Psychol Org Behav. 2020;7:283-313.
This review discusses the importance of teamwork in supporting safety, psychological states driving effective safety performance, organizational- and team-level characteristics impacting safety performance, and the role of teams in safety management.
McLeod PL, Cunningham QW, DiazGranados D, et al. Health Care Manag Rev. 2021;46:341-348.
Effective teamwork is critical to ensuring patient safety, particularly in intensive settings such as critical care. This paper describes a “hackathon” – an intensive problem-solving event commonly used in computer science designed to stimulate creative solutions – focused on the challenges encountered by rapid team formation in critical care settings (such as for cardiac resuscitation). Hackathon teams were multidisciplinary, comprised of healthcare professionals and academics with expertise in communications, psychology and organizational sciences. The paper briefly discusses the three solutions proposed, and the impacts of leveraging this approach for solving other problems specific to health care management.
Chang BH, Hsu Y-J, Rosen MA, et al. Am J Med Qual. 2020;35:37-45.
Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.
Bisbey TM, Reyes DL, Traylor AM, et al. Am Psychol. 2019;74:278-289.
Team development is an important focus of safety improvement. This article provides an overview of team training science and highlights aviation, military, and health care failures that motivated research to understand the psychology of teams. The authors emphasize the importance of multidisciplinary collaboration and the contributions of psychologists as research partners in this work.
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.