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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 - 6 of 6 Results
Crawford TC, Conte J, Sanchez JA. Surg Clin North Am. 2017;97:801-810.
Team strategies are key to improving complex care processes. This review focuses on cardiothoracic surgery and the need for team approaches to enhance the safety of care in this specialty. The authors suggest that nontechnical skill development for surgical team leaders and structured communication can improve team performance.
Sanchez JA, Lobdell KW, Moffatt-Bruce SD, et al. Ann Thorac Surg. 2017;103:1693-1699.
Incident analysis enables learning from errors. This commentary explores elements of successful event investigation such as determining causal factors, describes root cause analysis, and reviews biases that can influence such investigations.
Sanchez JA, Ferdinand FD, Fann J. Ann Thorac Surg. 2016;101:426-33.
The Society of Thoracic Surgeons National Database collects data to promote transparency and enhance technical expertise. Exploring safety sciences in cardiothoracic surgery, this commentary discusses how human error, accident causation, and high reliability can improve safety of care delivered by cardiac surgical teams.
Marsteller JA, Wen M, Hsu Y-J, et al. Ann Thorac Surg. 2015;100:2182-9.
This study found that cardiac surgical teams had a more positive safety culture (as measured by the AHRQ Hospital Survey on Patient Safety Culture) than other surgical teams. Similar to prior studies in which managers reported a more positive safety culture than frontline staff, in this study surgeons reported more optimal safety culture compared to nurses and perfusionists. This gap in perceived safety culture requires further study.
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.