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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, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Guo W, Li Y, Temkin-Greener H. J Am Med Dir Assoc. 2021;Epub May 25.
This study examined the association between patient safety culture (PSC) 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. 
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 2021 observance is will be held September 13-19.

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(22):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; Epub Jan 6.
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 Qual Health Care. 2020;Epub Nov 10 .
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. 2020;Epub Nov 19.
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.  
Britton CR, Hayman G, Stroud N. J Perioper Pract. 2021;31(1-2):44-50.
The COVID-19 pandemic has highlighted the crucial role that team and human factors play in healthcare delivery. This article describes the impact of a human factors education and training program focused on non-technical skills and teamwork (the ONSeT project) – on operating room teams during the pandemic. Results indicate that the project improved team functioning and team leader responsiveness.

Zheng F ed. Surg Clin North Am. 2021;101(1):1-160.  

Surgical safety is a recognized area of emphasis in patient safety improvement. Articles in this special issue cover topics such as human factors, checklists, teamwork, and telemedicine as a safe support mechanism. 

Multidisciplinary teams at the University of Kansas Hospital sought to improve patient outcomes from obstetric emergencies by rehearsing team responses in simulations to emergent situations that can occur during a delivery. Using the PRactical Obstetric MultiProfessional Training (or PROMPT) curriculum, teams rehearsed flexible emergency care scenarios in order to achieve an optimal response, and then used this experience to improve their response to a real emergency. The PROMPT program requires the participation of all healthcare providers who might be called on to manage a pregnant women and is repeated annually. Over the eleven years the program was employed at the University of Kansas Hospital, there was a progressive reduction in the rates of cesarean delivery, brachial plexus injury (transient and permanent), and hypoxic ischemic encephalopathy at term, low umbilical artery pHs, decision-to-delivery times for fetal distress, the need for blood transfusion. The rate of shoulder dystocia was relative stable. These improvements are consistent with both RCTs and case control studies conducted worldwide evaluating the PROMPT program. In 2018, institutional priorities at the University of Kansas Hospital shifted and the team transitioned away from using PROMPT as their training model. However, PROMPT training is implemented widely internationally and is available in North America from PROMPT North America. Other organizations in the United States implementing PROMPT include University of Washington M.C., Baylor Scott & White University Medical Center, and Redington Fairview General Hospital, among others. Participant course materials can be purchased from Cambridge University Press and on Amazon.

Gavin N, Romney M-LS, Lema PC, et al. BMJ Leader. 2021;5:39-41.
Developed in the field of aviation, crew resource management (CRM) is used to teach teamwork and effective communication and has been used extensively in patient safety improvement efforts. This commentary describes four New York metropolitan area emergency departments’ experience applying (CRM) principles at an organizational level in responding to the current COVID-19 pandemic as well as future crises.
Harper PG, Schafer KM, Van Riper K, et al. J Am Pharm Assoc (2003). 2020;Epub Sept 14.
This article a systematic team-based care approach to medication reconciliation implemented in four family medicine residency clinics. After implementation, there was a significant increase in the number of visits with physician-documented medication reconciliation and this increase was sustained one year later.

This piece discusses the concept of Safety Across the Board and reviews the three key components necessary for successful implementation in a healthcare organization: culture, strong safety processes, and engagement.

Social worker/nurse practitioner teams collaborate with a larger interdisciplinary team and primary care physicians to develop and implement individualized care plans for seniors and other high-risk patients. The social worker/nurse practitioner team also proactively manages and coordinates the patient's care on an ongoing basis through regular telephone and in-person contact with both patients and providers. The program, known as Geriatric Resources for Assessment and Care of Elders (GRACE), improved the provision of evidence-based care; led to significant improvements in measures of general health, vitality, social functioning, and mental health; reduced emergency department visits, hospital admissions, readmissions, and total bed days; and generated high levels of physician and patient satisfaction. These successes have been across a variety of health system contexts, including: a VA medical center, primary care health centers, and as a part of a Medicare Advantage plan. A recent analysis found that the reduction in service usage saved the VA medical center $200k per year for the 179 veterans enrolled in GRACE. Another analysis in primary care health centers found that the program was cost neutral for high-risk patients in the first 2 years, and yielded savings by year 3.

The program was initially designed to serve low-income seniors, but has subsequently been replicated with different populations, including adults of all ages who are high risk, Medicare beneficiaries who are 70+ with multiple comorbidities, and older veterans following an emergent hospital admission and discharge home.

Trinchero E, Kominis G, Dudau A, et al. Public Manag Rev. 2020;22.
Employing a mixed-methods approach, this study found that teamwork (directly and indirectly) positively impacted professionals’ safety behavior. Teamwork indirectly impacted safety behavior by increasing individual’s positive psychological capital, thereby increasing their self-efficacy and resilience. These findings emphasize the role of hospital leadership and middle management in creating an organizational culture of safety
JN Learning. 2020.
Disruptive behavior is a recognized deterrent to safe communication, sharing of concerns and teamwork. This educational program highlights a study that measured the impact of unprofessional physician behavior on patient care and features Dr. William Cooper and Dr. Gerald Hickson as speakers.
Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22(1):13-27.
In this narrative review, the authors contrast approaches to teamwork in healthcare with current concepts in safety science. The authors encourage moving past a ‘reductionist’ (reducible through information) approach to teamwork training and discuss the potential benefit from a more interdisciplinary approach towards teamwork and safety science research by integrating medical and social science disciplines, moving towards a ‘macro’ view of health care delivery, and evaluating how socioeconomic factors influence both healthcare systems and individual practitioners.