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.
Pradarelli JC, Yule S, Smink DS. JAMA Surg. 2020;155:438-439.
This article describes an online training module for surgeons to learn and assess nontechnical skills using the Nontechnical Skills for Surgeons (NOTSS) framework (eNOTSS). This platform could support nontechnical skills learning for a global audience. Next steps for platform development and implementation include creating capability for personalized feedback on nontechnical skills and garnering buy-in from health system leadership.
Davis A, Jones S, Crowell-Kuhnberg AM, et al. Surgery. 2017;161:1348-1356.
Communication failures in the operating room are a well-recognized threat to patient safety. Researchers observed and analyzed communication across seven operating room teams during a simulated emergency using a closed-loop communication framework. They found that communication patterns varied by specialty and that the patient's clinical status influenced whether directed communication resulted in a response.
Nontechnical skills are gaining interest as a way to enhance surgical team performance. This commentary describes a model for identifying, training, and assessing surgeon competencies in a defined set of nontechnical skills during pediatric surgery.
Direct observation of postoperative handoffs revealed that clinicians' subjective impressions and concerns were a critical component of a high-quality transfer of care and were considered more important than the transmission of standard clinical information.
Reader TW, Flin R, Mearns K, et al. BMJ Qual Saf. 2011;20:1035-42.
Situational awareness refers to the degree to which perception matches reality. This study assessed situational awareness of intensive care unit teams through direct observation of team rounds and assessment of the degree to which team members were able to anticipate clinical deterioration.
Jackson J, Sarac C, Flin R. Curr Opin Crit Care. 2010;16:632-8.
This review discusses the role of safety culture surveys in assessing safety climate at the unit and hospital level, and explores the relationship between survey results and safety behaviors and outcomes.
Flin R, Patey R, Jackson J, et al. Med Educ. 2009;43:1147-55.
First-year medical students had positive attitudes toward patient safety, but little knowledge of how to report or respond to errors. A case in which a medical student failed to report an error is discussed in this AHRQ WebM&M commentary.
Patey R, Flin R, Cuthbertson BH, et al. Qual Saf Health Care. 2007;16:256-9.
This study describes the development and implementation of a medical student curriculum that focuses on patient safety principles and skills. Although the module was rated highly, participants pointed out the difficulty in translating the skills into practice.
The author discusses current trends in using safety climate questionnaires to measure safety culture in health care organizations. This article is part of a special issue that includes several papers on improving safety culture.