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.
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...
Researchers deployed the Norwegian version of the Safety Attitudes Questionnaire, a measure of safety culture, across long-term care facilities and found significant variations in scores. They conclude that safety culture measurement may be useful to align resources with needs to support patient safety.
Ruskin KJ, Stiegler MP, Rosenbaum SH, eds. New York, NY: Oxford University Press; 2016. ISBN: 9780199366149.
The perioperative setting is a high-risk environment. This publication discusses the clinical foundations and application of safety concepts in perioperative practice. Chapters cover topics such as human factors, error management, cognitive aids, safety culture, and teamwork.
Casali G, Cullen W, Lock G. J Thorac Dis. 2019;11:S998-S1008.
Nontechnical skills, such as teamwork, communication, and leadership, are essential human-centered components of safe surgical practice. This commentary discusses contextual characteristics needed to support nontechnical skill development to improve health care outcomes. The authors recommend a cultural shift away from focusing on technical performance to one that incorporates training in nontechnical skills.
Sturrock J. Edinburgh, Scotland: The Scottish Government; May 2019. ISBN: 9781787817760.
Disrespectful and unprofessional behaviors are a common problem in health care. The report examines cultural issues at a National Health Service trust that affected the transparency needed to report disruptive behaviors and that limited conversation needed to facilitate local actions and improvement. Recommendations for the leadership, organizational, and system levels are provided to enable constructive change.
Davidson M, Brennan PA. Br J Oral Maxillofac Surg. 2019;57:407-411.
Aviation has provided health care with insights regarding how systems approaches, blame-free reporting, and teamwork can prevent failure. This commentary summarizes tactics used in aviation that have been applied to surgery in support of efforts to reduce patient harm.
Chang BH, Hsu Y-J, Rosen MA, et al. Am J Med Qual. 2020;35:37-45.
Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.
Patients with end-stage renal disease are vulnerable to adverse events in dialysis. This commentary outlines a team-based approach to improving safety in dialysis care. The authors highlight the importance of multidisciplinary teamwork, accountability, and coleadership to develop high-functioning teams for safe dialysis.
Teamwork is a key element of safe medical care. This commentary examines teamwork in gastroenterology and offers a developmental framework of high-performing teams. The author spotlights the role of experiential learning and formal educational programs in this setting and notes the importance of psychological safety, trainee observation, and organizational culture.
Baxter R, Taylor N, Kellar I, et al. BMJ Qual Saf. 2019;28:618-626.
This qualitative study compared four high-performing geriatric inpatient units with four average-performance units in order to understand factors that contribute to high performance. The authors conclude that the safety practices did not differ between the high versus average performers. Instead, optimal teamwork and positive safety culture led the high-performing wards to implement these safety practices in a more effective way.
Pattni N, Arzola C, Malavade A, et al. Br J Anaesth. 2019;122:233-244.
Effective teamwork and communication are critical to ensuring patient safety in the busy environment of the operating room. This review examined the evidence on preparing staff to challenge authority in the perioperative environment. Common themes that affect speaking up included hierarchy, organizational culture, and education. Teaching that promotes open communication in the postgraduate environment and utilizing tactics such as simulation training can help address barriers to challenging authority.
Profit J, Sharek PJ, Cui X, et al. J Patient Saf. 2020;16:e310-e316.
Prior research has shown that health care worker perceptions of safety culture may vary across different neonatal intensive care units (NICUs). Less is known as to how perceptions of NICU safety culture relate to NICU quality of care. In this cross-sectional study involving 44 NICUs, researchers found a significant relationship between safety climate and teamwork ratings and a lack of health care–associated infections, but no relationship with regard to the other performance metrics examined in the study.
Elmontsri M, Banarsee R, Majeed A. JRSM Open. 2018;9:2054270418786112.
Health care safety is a global concern. This review examined the literature on improvement experience from developed countries and identified common themes. The authors recommend a patient-centered, systems-oriented approach built on leadership, teamwork, transparency, and communication as key elements for effectively implementing improvement efforts in developing countries.
Zaheer S, Ginsburg LR, Wong HJ, et al. BMJ Open Qual. 2018;7:e000433.
Establishing a culture of safety within health care organizations requires strong leadership support. This cross-sectional survey study of nurses, allied health professionals, and unit clerks working in the inpatient setting at a single hospital found that positive perceptions of senior leadership support for safety and positive perceptions of teamwork were associated with positive perceptions of patient safety. In addition, when staff perceived senior leadership support for safety to be lacking, the positive impact of direct managerial leadership on staff perceptions of patient safety was more pronounced.
Systems solutions are often focused on creating improvements at the organizational or blunt end. This commentary argues that the concept has relevance at the sharp end as well. The author explores the role of clinical teams in applying systems thinking to reduce blame, improve learning from harm, and address persistent challenges to patient safety.
Collaboratives are a recognized strategy to support large-scale improvement. This program will work to apply a framework for measuring and monitoring patient safety innovation and outcomes throughout a cohort of Canadian hospitals to foster new improvement strategies.
Roberson DW, Kirsh ER. Otolaryngol Clin North Am. 2019;52:1-9.
High-reliability organizations have developed methods for achieving safety despite hazardous conditions. This review summarizes the systems science, organizational structure, and interpersonal working methods that enable high-risk industries like health care to practice reliably and learn from mistakes.
Gerada C, Chatfield C, Rimmer A, et al. BMJ. 2018;363:k4147.
Systems must be designed to support staff well-being and safety. This commentary introduces an ongoing collection of materials devoted to exploring issues that affect physician wellness. The authors suggest that an understanding of the systems and cultural factors that diminish clinician well-being is needed to maintain a physically, emotionally, and mentally healthy clinician workforce.
Welp A, Meier LL, Manser T. Crit Care. 2016;20:110.
Emotional exhaustion is a component of burnout—a critical patient safety issue. Teamwork promotes resilience and thus may protect against burnout and promote patient safety. However, it is unclear how teamwork, burnout, and patient safety interact in a safety culture. This prospective study of critical care interprofessional teams found that clinicians' emotional exhaustion affects teamwork, which leads to worsening clinician reports of patient safety. The authors suggest addressing clinicians' emotional exhaustion prior to team training in order to best augment patient safety in the intensive care unit. A PSNet interview discusses strategies to enhance clinicians' emotional resilience.
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