Azyabi A. Int J Environ Res Public Health. 2021;18:2466.
Accurate measurement of patient safety culture (PSC) is essential to improving patient safety. This review summarizes the results of 66 studies on PSC in hospitals. Multiple instruments were used to assess PSC, including the Hospital Survey on Patient Safety Culture (HSPSC) and the Safety Attitudes Questionnaire (SAQ). Teamwork and organization and behavioral learning were identified as critical factors impacting PSC and should be considered in future research.
Preckel B, ed. Best Pract Res Clin Anaesthesiol. 2021;35(1):1-154.
The field of anesthesiology has realized impressive improvements in safety, yet challenges still exist in its practice. This special issue provides discussions on a variety of concerns that require continued effort, including use of early warning scores, differences associated with sex and gender, and use of incident reporting systems.
Avesar M, Erez A, Essakow J, et al. Diagnosis (Berl). 2021;8:358-367.
Disruptive and rude behavior can hinder teamwork and diminish patient safety. This randomized, simulation-based study including attendings, fellows, and residents explored whether rudeness during handoff affects the likelihood for challenging a diagnostic error. The authors found that rudeness may disproportionally hinder diagnostic performance among less experienced physicians.
Nydoo P, Pillay BJ, Naicker T, et al. Scand J Public Health. 2020;48:629-637.
Maternity care can be a high-risk environment. This literature review summarizes the prevalence, risk factors, coping strategies, and recovery processes for ‘second victims’, with an emphasis on obstetric care.
This review expands upon previous work evaluating implementation strategies for high-reliability organizations. Review findings indicate that health care system adoption of high-reliability principles is associated with improved outcomes, but the level of evidence is low. Future research should include concurrent control groups to minimize bias and focus on whether certain high-reliability frameworks, metrics, or intervention components lead to greater improvements.
Rainbow JG, Drake DA, Steege LM. West J Nurs Res. 2020;42:332-339.
This study explored the relationships between nurse fatigue, burnout, psychological well-being, team vitality, and patient safety, and the role of presenteeism as a potential mediator. Authors found strong relationships between workplace influences and job-stress presenteeism, and between job-stress presenteeism and patient safety outcomes, including lower rates of event reporting and perceptions of patient safety.
Hartwig A, Clarke S, Johnson S, et al. Org Psychol Rev. 2020;10:169-200.
This systematic review examined nature of workplace team resilience, how it is defined, the individual factors associated with team resilience, and the relationship between individual- and team-level resilience. The results of the review informed the development of a theoretical framework conceptualizing team resilience and integrating different conceptual components of team resilience.
Kim S, Appelbaum NP, Baker N, et al. J Healthc Qual. 2020;42:249-263.
This review summarizes studies of training programs targeting healthcare professionals’ speaking up skills. The authors found that most training programs were limited to a one-time training delivered to a single profession (i.e., limited to doctors or nurses). The majority of programs addressed legitimate power (i.e., social norms such as titles) but few addressed other types of power (e.g., reward or coercive power, personal resources) or the non-verbal (i.e., emotional) skills required in speaking-up behaviors.
Browne J, Braden CJ. Am J Crit Care. 2020;29:182-191.
This study explored the relationship between nursing workload and turbulence, or unexpected work complexities and activities. Using responses from a survey of members of the American Association of Critical-Care Nurses, the authors identified several types of turbulence, such as changes in acuity, interruptions, distractions, lack of training, and administrative demands. They found that turbulence was strongly correlated with patient safety risk whereas workload had the weakest association. Acknowledging the difference between nursing workload and turbulence can enhance our ability to target resources in nursing care and improve patient outcomes.
Giardina TD, Royse KE, Khanna A, et al. Jt Comm J Qual Patient Saf. 2020;46:282-290.
This study analyzed self-reported adverse events captured on a national online questionnaire to determine the association between patient-reported contributory factors and patient-reported physical, emotional or financial harm. Contributory factors identified in the analysis focused on issues with health care personnel communication, fatigue, or response (e.g., doctor was slow to arrive, nurse was slow to respond to call button). These patient-reported contributory factors increased the likelihood of reporting any type of harm.
Stovall M, Hansen L, van Ryn M. J Nurs Scholarsh. 2020;52:320-328.
This article provides a critical review of the literature about moral injury observed in nurses after a patient safety incident. The authors describe ‘moral injury’ as an experience violating deeply held moral values and beliefs, which can place and individual at risk for burnout and post-traumatic stress disorder. Moral injury symptoms identified in this review included guilt, shame, spiritual-existential crisis, and loss of trust. The authors posit that moral injury may be a more appropriate term for what has been historically referred to as the ‘second victim’ phenomenon.
O’Donovan R, McAuliffe E. BMC Health Serv Res. 2020;20:101.
Organizational cultures that encourage psychological safety has been shown to increase safe healthcare practices. This systematic review evaluated fourteen studies targeting psychological safety, speaking up and voice behavior within healthcare settings; studies primarily used educational interventions including simulation (5 studies), video presentations (2 studies), case studies (3 studies) or workshops (1 study). While some interventions showed improvement in psychological safety, this was not consistently demonstrated across studies. The authors note that the ability to demonstrate improvements were limited by lack of objective outcome measures and the inability of educational interventions alone to result in behavior change.
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