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.
Lee SE, Repsha C, Seo WJ, et al. Nurse Educ Today. 2023;126:105824.
“Horror room” simulations are used to help train medical students to identify patient safety hazards. This systematic review of 16 studies found that “horror room” simulations are more common in Western countries and focus on medication-related or procedure-related incidents. The authors highlight the need for research establishing parameters regarding the ideal size and composition of the team to yield the highest impact on learners.
Lee SE, Hyunjie L, Sang S. West J Nurs Res. 2023;45:176-185.
Effective nurse leadership can result in improved safety climate and willingness to report errors. This review identified 14 studies of the impact of nurse leadership on adverse patient outcomes, rates of nursing errors, error reporting and error reporting intention, quality of care, and patient satisfaction. Transformational leadership in particular showed a positive relationship with improved outcomes.
Havaei F, MacPhee M, Dahinten S. J Adv Nurs. 2019;75:2144-2155.
This study looked at the impact of two different models of delivering care by nurses, team versus total care, on quality of care and adverse events. The authors found that the team nursing model reported higher frequency of adverse events when there were licensed practical nurses on the team.
Lee SE, Vincent C, Dahinten S, et al. J Nurs Scholarsh. 2018;50:432-440.
This secondary analysis combined survey data from individual nurses with hospital safety culture data and found that both individual characteristics such as education level and hospital characteristics such as safety culture were associated with risks of medication administration errors and falls. The authors conclude that improving safety culture should be a high priority.
Lee SE, Scott LD, Dahinten S, et al. West J Nurs Res. 2019;41:279-304.
This literature review found that the relationship between safety culture and patient safety outcomes is inconsistent across studies. Researchers recommend use of a theoretical framework and validated safety culture instruments to shed light on the correlation between safety culture and patient harm.
Lee SE, Scott LD. West J Nurs Res. 2018;40:121-145.
The health care environment is known to influence teamwork and the culture of safety. This integrative review explored the literature to clarify the relationship between nurses' work environment and patient safety. The authors found weak definitional concurrence and measure inconsistency in the evidence base and advocate for improved research design to support future investigation in this area.
Scott LD, Arslanian-Engoren C, Engoren MC. Am J Crit Care. 2014;23:13-23.
Sleep deprivation can worsen clinical performance. Early studies on the effects of fatigue in clinical trainees formed some of the basis behind duty hour restrictions for resident physicians. This study surveyed intensive care unit (ICU) nurses about levels of fatigue and clinical decision-making. Nurses who regretted a clinical decision were more apt to be fatigued and to work 12-hour shifts. Sleep deprivation among ICU nurses was found to be common, with almost three-quarters of surveyed nurses having lost 8 or more hours of sleep in a 5-day period. The study was limited by a very low (17%) response rate, potentially biasing the results. Prior research has linked extended nursing shift lengths with compromised patient safety.
Keenan G, Yakel E, Lopez KD, et al. J Am Med Inform Assoc. 2013;20:245-51.
Direct observation of ward nurses' communication patterns revealed that poor interdisciplinary communication and the lack of a readily accessible care plan overview within the electronic medical record greatly inhibited nurses' situational awareness.
Scott LD, Hofmeister N, Rogness N, et al. J Nurs Adm. 2010;40:233-40.
This study describes the successes and challenges associated with implementing a formal program to combat fatigue among nurses. Although the program was well received, organizational culture and lack of resources were perceived as barriers to wider implementation.
Scott LD, Rogers AE, Hwang W-T, et al. Am J Crit Care. 2006;15:30-7.
The investigators reviewed logbook entries from 502 critical care nurses asked to record information about hours worked, sleep-wake patterns, and errors or near misses. They found that the risk of error doubled after a shift of 12.5 hours or longer.
Rogers AE, Hwang W-T, Scott LD, et al. Health Aff (Millwood). 2004;23:202-212.
This AHRQ-funded study demonstrated that the risk of error increased in association with extended work shifts, overtime, or longer than 40-hour work weeks. Using logbooks from nearly 400 nurses sampled out of a larger group from the American Nurses Association, investigators determined that an alarmingly high percentage of nurses report working extended hours. For those shifts longer than 12.5 hours, the error rate increased notably. The authors advocate for continued attention to relationships between nursing work hours and patient safety, building on past research that linked staffing to poor patient outcomes.