Skip to main content

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.

Search All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Displaying 1 - 20 of 635 Results
Rose SC, Ashari NA, Davies JM, et al. CJEM. 2022;24:695-701.
Debriefing is used to enhance individual and team communication and to facilitate real-time learning opportunities after a critical event. This study evaluated a charge nurse-facilitated clinical debriefing program used in Emergency Departments (EDs) in Alberta, Canada. Qualitative analyses identified several themes underscoring the impact of the debriefing program – the impacts on clinical practice and patient care, impacts on psychological safety and teamwork, stress management, and the emotional acknowledgement after critical events – and barriers to debriefing.
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.
Schilling S, Armaou M, Morrison Z, et al. PLoS ONE. 2022;17:e0272942.
Effective teamwork is critical in acute and intensive care settings. This systematic review of reviews and thematic analysis identified four key factors that frame the evidence on interprofessional teams in acute and intensive care settings – (1) team internal procedures and dynamics, such as cohesion, organizational culture, and leadership influence; (2) communicative processes; (3) organizational and team-extrinsic influences, such as team composition, hierarchy, and interprofessional dynamics, and; (4) team outcomes, including both patient and staff outcomes.
Westbrook JI, McMullan R, Urwin R, et al. Intern Med J. 2022;52:1821-1825.
The COVID-19 pandemic dramatically impacted team functioning in healthcare settings. This survey of nearly 1,600 clinical and non-clinical staff at five Australian hospitals did not identify any perceived increases in unprofessional behaviors during the pandemic and 44% of respondents cited improvements in teamwork.
WebM&M Case August 31, 2022

A 49-year-old woman was referred by per primary care physician (PCP) to a gastroenterologist for recurrent bouts of abdominal pain, occasional vomiting, and diarrhea. Colonoscopy, esophagogastroduodenoscopy, and x-rays were interpreted as normal, and the patient was reassured that her symptoms should abate. The patient was seen by her PCP and visited the Emergency Department (ED) several times over the next six months. At each ED visit, the patient’s labs were normal and no imaging was performed.

Redley B, Douglas T, Hoon L, et al. J Adv Nurs. 2022;78:3745-3759.
Frontline care providers such as nurses play an important role in reducing preventable harm. This study used qualitative methods (direct observation and participatory workshops) to explore nurses’ experiences implementing harm prevention practices when admitting an older adult to the hospital. Researchers identified barriers (e.g., lack of resources, information gaps) and enablers (e.g., teamwork, reminders) to harm prevention during the admission process.
Farrell TW, Butler JM, Towsley GL, et al. Int J Environ Res Public Health. 2022;19:5975.
A robust culture of safety encourages open communication between team members. Certified nursing assistants (CNAs) and nurses in nursing homes were asked about the extent to which their input about residents was valued by the other team members. CNAs reported they felt valued by other CNAs and nurses, but less valued by physicians and pharmacists.
Society for Simulation in Healthcare.
Simulation provides a safe space to observe behaviors and generate constructive feedback to enhance individual and team performance. This website provides promotional materials for an annual campaign to raise awareness of professionals that use simulation to develop teamwork, communication, and crisis management skills in health care. The 2022 observance will be held September 12-16.
Perspective on Safety March 31, 2022

A psychologically safe environment for healthcare teams is desirable for optimal team performance, team member well-being, and favorable patient safety outcomes. This piece explores facilitators of and barriers to psychological safety across healthcare settings. Future research directions examining psychological safety in healthcare are discussed.

Hennus MP, Young JQ, Hennessy M, et al. ATS Sch. 2021;2:397-414.
The surge of patients during the COVID-19 pandemic forced the redeployment of non-intensive care certified staff into intensive care units (ICU). This study surveyed both intensive care (IC)-certified and non-IC-certified healthcare providers who were working in ICUs at the beginning of the pandemic. Qualitative synthesis identified five themes related to supervision; quality and safety of care; collaboration, communication, and climate; recruitment, scheduling and team composition, and; organization and facilities. The authors provide recommendations for future deployments.
Ottawa, ON: Canadian Patient Safety Institute; 2008.
This initative defines competency domains for safe health care and outlines educational practices to achieve them. The 2nd edition of the Patient Safety Competencies was released in 2020. 
Curated Libraries
September 13, 2021
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, collaborative initiatives, teamwork, and trigger tools.
Guo W, Li Y, Temkin-Greener H. J Am Med Dir Assoc. 2021;22:2384-2388.e1.
This study examined the association between patient safety culture (PSC) measured by the Nursing Home Survey on Patient Safety Culture and community discharge of long-term care (LTC) residents.  Results show that two domains of PSC- teamwork and supervisor expectations and actions regarding patient safety- are significantly associated with increased likelihood of discharge to a community setting. Focusing on these domains to improve patient safety culture may also increase community discharge rates. 
Perspective on Safety March 10, 2021

In this PSNet Annual Perspective, we review key findings related to improvement strategies when communicating with patients and different structured communication techniques to improve communication across providers. Lessons learned from innovative approaches explored under COVID-19 that could be considered as usual care resumes are also discussed.

De Brún A, Anjara S, Cunningham U, et al. Int J Environ Res Public Health. 2020;17:8673.
Leadership has an important role in promoting a culture of safety and enabling necessary changes to enhance patient safety. This article summarizes the design, pilot testing, and refinement of the Collective Leadership for Safety Culture (Co-Lead) program, which offers a systematic approach to developing collective leadership behaviors to promote effective teamwork and enhance safety culture.
Bacon CT, McCoy TP, Henshaw DS. J Nurs Adm. 2021;51(1) :12-18.
Lack of communication and interpersonal dynamics can contribute to failure to rescue. This study surveyed 262 surgical staff about perceived safety climate, but the authors did not find an association between organizational safety culture and failure to rescue or inpatient mortality.  
Kandasamy S, Vanstone M, Colvin E, et al. J Eval Clin Pract. 2021;27:236-245.
Physicians often experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. Based on in-depth interviews with emergency, internal, and family medicine physicians, this qualitative study explores how physicians experience and learn from preventable medical errors. In addition to exploring themes around the physician’s emotional growth and professional development, the authors discuss the value of sharing and learning from these experiences for colleagues and trainees.  
Kjaergaard-Andersen G, Ibsgaard P, Paltved C, et al. Int J Health Care Qual. 2021;33:mzaa148.
Simulation training is used by hospitals to improve patient care. This study describes the experience of one Danish hospital shifting from simulation training at external centers to in situ training. The shift to in situ training identified several latent safety threats (e.g., equipment access, lack of closed-loop communication, out-of-date checklists) and these findings led to practice changes.  
Orth J, Li Y, Simning A, et al. Gerontologist. 2021;61:1296-1306.
Nursing home patient safety culture is associated with healthcare quality and patient outcomes. This large cross-sectional study of nursing homes in the United States found that speaking-up behavior and communication openness were associated with a decreased risk of in-residence death among older adults with dementia. This association was strong in nursing homes located in states with higher nursing home nurse staffing requirements.