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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 34 Results
Gregory ME, Hughes AM, Benishek LE, et al. J Patient Saf. 2021;17:e47-e70.
High reliability remains an elusive goal for health care organizations. The authors of this study posit that medical teams’ ABCs – attitudes, behaviors, and cognitions – are critical for high-reliability, enhancing team adaptation and increasing patient safety. The article outlines practical tools and educational strategies that can be leveraged by a variety of healthcare organizations to improve team-based care.
Traylor AM. Am Psychol. 2021;76:1-13.
The COVID-19 pandemic has dramatically affected the psychological and emotional well-being of health care workers. This article summarizes the COVID-19-related psychological effects on healthcare workers and the detrimental impact on team effectiveness. The authors recommended actions to mitigate the effects of stress on team performance and patient outcomes and discuss how teams can recover and learn from the current crisis to prepare for future challenges.
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.
Yamada NK, Catchpole K, Salas E. Semin Perinatol. 2019;43:151174.
Human factors are frequently an important contributing factor to patient safety events. This review describes the role of human factors in patient safety and presents three case studies of human factors affecting care in the NICU. A PSNet Human Factors Primer on human factors expands on these concepts.
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.
Dietz AS, Salas E, Pronovost P, et al. Crit Care Med. 2018;46:1898-1905.
This study aimed to validate a behavioral marker as a measure of teamwork, specifically in the intensive care unit setting. Researchers found that it was difficult to establish interrater reliability for teamwork when observing behaviors and conclude that assessment of teamwork remains complex in the context of patient safety research.
Fiscella K, Mauksch L, Bodenheimer T, et al. Jt Comm J Qual Patient Saf. 2017;43:361-368.
Research on teamwork as a key component of safe care delivery has primarily focused on the hospital setting. This commentary highlights six elements that enable development, functionality, and assessment of teamwork in the ambulatory setting.
Marlow SL, Hughes A, Sonesh SC, et al. Jt Comm J Qual Patient Saf. 2017;43:197-204.
This systematic review found that team training programs primarily focus on improving communication among providers, generally involve simulation, and usually assess efficacy with self-report. The authors conclude that team training is improving but remains suboptimal.
Hughes A, Gregory ME, Joseph DL, et al. J Appl Psychol. 2016;101:1266-304.
In teamwork training, multidisciplinary health care teams learn to respond effectively to acute situations. Prior studies of team training show improvements in safety culture, but its effect on patient outcomes has been mixed. This meta-analysis of 129 studies found that team training consistently led to enhanced participant satisfaction and skills. These improvements were present across different health care settings and team composition. Investigators also determined that team training positively affects length of stay and mortality, although they caution that few of the primary studies analyzed included these patient outcomes. The authors suggest that team training should be widely implemented and that further studies should evaluate its effect on length of stay, patient satisfaction, and mortality. A PSNet interview discussed how team training from other industries can be applied to health care.
Lyons R, Lazzara EH, Benishek LE, et al. Jt Comm J Qual Patient Saf. 2015;41:115-125.
Updating an earlier article that revealed a set of generalizable debriefing strategies, this commentary describes 13 best practices for enhancing the effectiveness of team debriefings in medical simulations. Organized in three categories consisting of preparation, facilitator responsibilities during the session, and considerations for the content discussed, the authors outline recommendations to augment learning and team performance related to debriefings.
Keebler JR, Dietz AS, Lazzara EH, et al. BMJ Qual Saf. 2014;23:718-26.
This validation study found that the TeamSTEPPS questionnaire—which explores perceptions of teamwork within health care settings—reliably measures how staff perceive leadership, mutual support, situation monitoring, communication, and team structure. According to these findings, this instrument provides a valid way to assess teamwork for safety research and improvement efforts.
Lazzara EH, Benishek LE, Dietz AS, et al. Jt Comm J Qual Patient Saf. 2014;40:21-29.
This commentary outlines key factors to consider when designing simulation initiatives to enhance human performance in health care. The authors also provide examples of hospitals that have implemented approaches incorporating science, staff, supplies, space, support, systems, success, and sustainability in simulation-based training.
Wahr JA, Prager RL, Abernathy JH, et al. Circulation. 2013;128:1139-1169.
This scientific statement from the American Heart Association (AHA) reviews the current state of knowledge on safety issues in the operating room (OR) and provides detailed recommendations for hospitals to implement to improve safety and patient outcomes. These recommendations include using checklists and formal handoff protocols for every procedure, teamwork training and other approaches to enhance safety culture, applying human factors engineering principles to optimize OR design and minimize fatigue, and taking steps to discourage disruptive behavior by clinicians. AHA scientific statements, which are considered the standard of care for cardiac patients, have traditionally focused on clinical issues, but this article (and an earlier statement on medication error prevention) illustrates the critical importance of ensuring safety in this complex group of patients.