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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 48 Results
Gambashidze N, Hammer A, Wagner A, et al. J Patient Saf. 2021;17:e280-e287.
Correctly reporting, interpreting, and comparing patient safety culture (PSC) survey findings is critical to improving patient safety in hospitals. Nearly 1,800 physicians and nurses were surveyed using the Hospital Survey on Patient Safety Culture (HSOPS) to examine the influence of gender, profession, and managerial function on perception of patient safety culture. Results indicate that profession and managerial function had significant direct effects, while gender had indirect effects, on the Overall Perception of Patient Safety dimension. Hospitals should take these characteristics into account when interpreting PSC survey results.  
Schmutz JB, Meier LL, Manser T. BMJ Open. 2019;9:e028280.
Effective teamwork is a critical component of care coordination and patient safety. This systematic review assessed the relationship between teamwork processes and clinical and process outcome measures in an acute care setting. Outcome measures included both clinical outcomes, such as postoperative infection rates, and process measures, such as adherence to checklists intended to prevent patient harm. The authors found that teamwork was positively correlated with both outcome and process measures, regardless of the characteristics of the team or task.

GMS J Med Educ. 2019;36:Doc11-Doc22.

… 2019;36:Doc11-Doc22. … B. … M. … R. … B. … S. … L. … M. … K. … T. … A. … A. … A. … Y. … H. … B. … N. … M. … C. … J. … N. … … Hoffmann … Mitzkat … Mahler … Frankenhauser … Wu … Busch … Manser … B. Braun … M. Grünewald … R. Adam-Paffrath … B. …
Merrell SB, Gaba DM, Agarwala A, et al. Jt Comm J Qual Patient Saf. 2018;44:477-484.
Emergency manuals have been adopted from high reliability industries as a cognitive aid for guiding interprofessional teams during clinical crises. Investigators interviewed emergency manual users after an intraoperative cardiac arrest and conceptualized how the manual helped provide optimal care. A PSNet interview reviews more broadly how to achieve high reliability in health care.
Monaca C, Bestmann B, Kattein M, et al. J Patient Saf. 2020;16:90-97.
Safety culture is traditionally measured from the health care team's perspective. Researchers used a large online survey to develop and validate an 11-item scale to measure patients' perception of safety culture. A recent Annual Perspective explored the growing field of patient engagement in safety.
Stojkovic T, Marinkovic V, Jaehde U, et al. Res Social Adm Pharm. 2017;13:1159-1166.
Failure mode and effect analysis is a tool commonly used to proactively assess the reliability of health care processes and workflows. The authors describe the application of failure mode and effect analysis to identify failure modes in the dispensing of medications in the community pharmacy setting.
Weinger MB, Banerjee A, Burden AR, et al. Anesthesiology. 2017;127:475-489.
Simulation training has been increasingly employed in health care, largely due to its success in the aviation industry. Prior research suggests that simulation programs can lead to improved knowledge, skills, and behaviors among health care professionals. In this study, researchers video recorded 263 board-certified anesthesiologists performing two mannequin-based simulated emergencies to determine whether this type of simulation is a reliable way to evaluate competency. Blinded anesthesiologists then evaluated the recordings using standardized rating tools to assess the percentage of critical performance elements carried out and to provide an overall rating of participants' technical and nontechnical skills. In 284 of the simulated emergencies, the participating anesthesiologists completed 81% of the critical performance elements successfully. About 25% of the participants were given low overall ratings. The authors conclude that assessing anesthesiologists' skills in simulated medical emergencies can help identify opportunities for improvement and better inform continuing medical education initiatives. A past PSNet perspective discussed the literature on health care simulation.
Stojkovic T, Marinkovic V, Manser T. J Patient Saf. 2021;17:e515-e523.
This narrative review found that failure mode and effect analysis and sociotechnical probabilistic risk assessment have both been applied to medication dispensing. These methods have led to corrective actions that enhance medication safety. The authors recommend wider use of these tools across inpatient and outpatient health care settings.
Huckels-Baumgart S, Baumgart A, Buschmann U, et al. J Patient Saf. 2021;17:e161-e168.
Interruptions are known to contribute to medication administration errors. This pre–post study found that nurses experienced fewer interruptions and made fewer medication errors following the introduction of a separate medication room. These results demonstrate how changing the work environment can promote safety.
Welp A, Manser T. BMC Health Serv Res. 2016;16:281.
Teamwork and clinician well-being have important implications for patient safety. Researchers conducted a systematic review of the literature and found evidence supporting independent relationships between teamwork, clinician well-being, and patient safety. The authors propose a framework that addresses current limitations and suggest that further research is needed to better understand the causal relationships between the three concepts.
Welp A, Meier LL, Manser T. Crit Care. 2016;20:110.
Emotional exhaustion is a component of burnout—a critical patient safety issue. Teamwork promotes resilience and thus may protect against burnout and promote patient safety. However, it is unclear how teamwork, burnout, and patient safety interact in a safety culture. This prospective study of critical care interprofessional teams found that clinicians' emotional exhaustion affects teamwork, which leads to worsening clinician reports of patient safety. The authors suggest addressing clinicians' emotional exhaustion prior to team training in order to best augment patient safety in the intensive care unit. A PSNet interview discusses strategies to enhance clinicians' emotional resilience.
Mentis HM, Chellali A, Manser K, et al. Surg Endosc. 2016;30:1713-24.
This systematic review found that equipment and procedural distractions were the most severe distraction events during surgery, but irrelevant conversation and movement were the most frequent. This underscores the need to reduce distractions and incorporate management of distractions into surgical education.
Welp A, Meier LL, Manser T. Front Psychol. 2014;5:1573.
This Swiss study sought to determine the relationship between elements of clinician burnout and mortality, length of stay, and ratings of patient safety. The authors found that clinicians demonstrating symptoms of burnout had lower perceptions of patient safety in the intensive care unit. However, higher levels of burnout among clinicians were not linked to clinical outcomes.
Weinger MB, Gaba DM. Anesthesiology. 2014;120:801-6.
Emphasizing the value of human factors engineering approaches to improving safety in high-risk industries, this commentary outlines tactics, safety issues, interventions, and outcomes of these methods applied in health care. Interventions described included teamwork training, checklists, and safety culture.
J Public Health Res. 2013;2:e22-e33.
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Singer SJ, Rivard PE, Hayes J, et al. Jt Comm J Qual Patient Saf. 2013;39:349-360.
A program to engage frontline workers with management in addressing safety issues at the unit level paradoxically resulted in worse perceptions of safety culture. Although leadership involvement is critical to augment patient safety, this article indicates that simply increasing engagement does not always yield productive improvement efforts.