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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 20 Results
Galatzan BJ, Carrington JM. Res Nurs Health. 2021;44:833-843.
During handoffs, nurses are exposed to a variety of interruptions and distractions which may lead to cognitive overload. Using natural language processing, researchers analyzed ten audio-recorded change of shift handoffs to estimate the cognitive load experienced by nurses. Nurses’ use of concise language has the potential to decrease cognitive overload and improve patient outcomes.
Lafferty M, Harrod M, Krein SL, et al. J Am Med Inform Assoc. 2021;28:28(12).
Use of one-way communication technologies, such as pagers, in hospitals have led to workarounds to improve communication. Through observation, shadowing, interviews, and focus groups with nurses and physicians, this study describes antecedents, types, and effects of workarounds and their potential impact on patient safety.
Johnson AH, Benham‐Hutchins M. AORN J. 2020;111.
Unprofessional behaviors negatively impact teams and can undermine patient safety. This systematic review examined the influence of bullying on nursing errors across multiple healthcare settings. Fourteen articles were included in the review and four themes were identified: the influence of work environment; individual-level connections between bullying and errors; barriers to teamwork, and; communication impairment. While nurses perceive that bullying influences errors and patient outcomes, the mechanisms are unclear and more research is necessary to determined how bullying impacts nursing practice error.
Rhudy LM, Johnson MR, Krecke CA, et al. Worldviews Evid Based Nurs. 2019;16:362-370.
Nursing handoffs at change of shift are critical for nurses to exchange information about patients; disruptions have been associated with adverse events.  After observing 100 nurse-to-nurse handoffs and conducting four focus groups, authors identified multiple sources of disruptions including those by patients and family members, which accounted for half the interruptions outside of the nurse handoff dyad.  Nurses identified some interruptions as valuable and relevant to patient care.
Durham, NC: Duke Center for Healthcare Safety and Quality; June 2019.
Improving teamwork and communication is a continued focus in the hospital setting. This toolkit is designed to help organizations create a culture that embeds teamwork into daily practice routines. Topics covered include team leadership, learning and continuous improvement, clarifying roles, structured communication, and support for raising concerns.
Olmstead J. Nurs Manage. 2019;50:8-10.
Mistakes during handoffs from the emergency department (ED) to inpatient units can diminish patient safety. This commentary summarizes how one hospital sought to to avoid miscommunications and disruptions by blocking admission of ED transfers during shift report. However, researchers found that blocking patient transfers did not result in improvements. The project did devise a standardized handoff process that was ultimately employed across the organization as a patient safety strategy.
Patterson ES. Hum Factors. 2018;60:281-292.
Poor design of health information technology can lead to miscommunication, burnout, and inappropriate documentation. This review of the literature identified three practice deviations associated with health IT, including workflow disruption, inappropriate use of text fields, and use of handwritten paper or whiteboard notes instead of health IT. The author recommends improvements focused on electronic health record display to enhance communication.
Sun AJ, Wang L, Go M, et al. BMJ Qual Saf. 2018;27:156-162.
Interruptions can lead to errors, particularly when providers are sleep deprived. This retrospective cross-sectional study of pages sent to overnight general surgery and internal medicine physicians found that 27.7% were nonurgent. The authors assert that nonurgent paging contributes to alarm fatigue and suggest potential solutions.
Institute for Safe Medication Practices; ISMP.
Texting as a communication method in the clinical environment is convenient, but it introduces distraction that can result in error. This survey sought to track the prevalence of medical order texting to better understand its impact on care processes. 
Carlile N, Rhatigan JJ, Bates DW. BMJ Qual Saf. 2017;26:24-29.
Despite the ubiquity of smartphones, the vast majority of physicians still rely on one-way pagers for communication. This study analyzed the frequency and content of pages on an internal medicine service at a teaching hospital and compared the data to a similar study performed in 1988. Physicians received an average of 22 pages per day, of which 76% were deemed clinically relevant by independent reviewers and 82% required a response. This represented a nearly 50% increase in the volume of pages compared to 1988. Doctors on regionalized services (where patients were admitted to a common unit) received significantly fewer pages than those caring for patients on nonregionalized services, implying that regionalized services may aid face-to-face communication. As interruptions have been shown to negatively affect patient safety, the authors advocate for developing secure two-way methods of communication (such as secure text messaging) for nurses and physicians in order to improve the efficiency of communication around clinical issues.
Nguyen C, McElroy LM, Abecassis MM, et al. Int J Med Inform. 2015;84:101-10.
Pagers have been a mainstay for urgent clinician–clinician communication for many decades. Increasingly physicians are using a variety of electronic devices, including smartphones and Web-based technologies. This systematic review identified 16 articles that studied different technologies for urgent clinician communication. Each strategy had potential advantages and pitfalls. For example, smartphones are associated with decreased transmission time compared to pagers, but they also result in more clinician interruptions. There is very little evidence linking any specific communication method with benefits for patient care. Future study could more robustly explore which forms of communication are best for clinicians and patients. A prior AHRQ WebM&M commentary describes a case of serious patient harm related to a smartphone interruption.
Wu RC, Lo V, Morra D, et al. J Am Med Inform Assoc. 2013;20:766-77.
Safe patient care requires effective communication between health care providers. Hospitals currently use various communication strategies including alphanumeric pagers, smartphones, and Web-based communication tools. The utility and effectiveness of many such systems have not been tested. This ethnographic study of five teaching hospitals discusses the potential benefits and unintended effects of different communication systems. For instance, smartphones made it easier to respond to requests, but seemed to increase interruptions. An AHRQ WebM&M commentary illustrates a serious adverse event resulting from a smartphone interruption.

Rogers WA, ed. J Exp Psychol Appl. 2011;17(3):191-302.

Articles in this special issue explore the impact of cognition on health care activities such as patient identification, interruptions, and team communication.
Rivera-Rodriguez AJ, Karsh B-T. Qual Saf Health Care. 2010;19:304-312.
The majority of individual errors are due to failure to perform automatic or reflexive actions. A major risk factor for these "slips" is being interrupted or distracted while performing a task. This review examined the literature on the incidence, risk factors, and effects of interruptions in several clinical settings, ranging from outpatient clinics to the operating room. Although distractions are common and may be associated with increased risk for error, particularly if they occur during medication administration or signout, the authors point out that many interruptions may be necessary to communicate urgent clinical information. They argue for complexity theory–based research to delineate the harmful and beneficial aspects of interruptions, rather than for interventions that seek to simply eliminate interruptions. Checklists have been widely adopted as a means of preventing errors of omission, which may be precipitated by interruptions.
Laxmisan A, Hakimzada F, Sayan OR, et al. IntJ Med Inform. 2007;76:801-811.
This study evaluated factors that jeopardize safe decision-making using ethnographic observation and interviews. Using a high-paced emergency department (ED) setting, investigators discovered that interruptions occurred nearly every 10 minutes for attending physicians. Observed gaps in communication resulted from poor information flow complicated by inherent multitasking, shift changes, and other activities such as documentation time and utilization of computer resources. The authors present typical workflow patterns in the ED and provide a summary of interview responses to illustrate the taxing nature of cognitive overload facing the studied clinicians. They conclude that carefully designed technology can minimize the effect that interruptions and handoffs have on patient safety.
France DJ, Throop P, Walczyk B, et al. J Patient Saf. 2008;1:145-153.
This study evaluated the impact of a newly designed children's hospital on patient safety and job function. The investigators begin with a detailed discussion of the contextual factors involved in their hospital redesign, drawing on human factors approaches in safety interventions. They follow by presenting their hospital design process, sharing both unit and floor layouts aimed to ensure family-centered ideals. Results from the 270 clinical faculty and staff surveys suggested that the majority reported a better overall new facility, more efficient information and patient flow, and high ratings for work environment factors such as lighting and equipment availability. However, providers in intensive care settings expressed concern about the negative impact new designs played in team communications, rates of interruptions, and work processes. As perhaps expected, the findings demonstrated many benefits and some unanticipated consequences of the redesign efforts but ultimately reinforced the need for human factors expertise.