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.
Breakdowns in communication and teamwork are common contributors to adverse events and can compromise safety. As medical care becomes more complex, more teams and subspecialists are involved in a patient's care, which may lead to fragmentation of care and a lack of clear ownership. This three-part series on teamwork highlights the challenges surrounding interprofessional communication and collaboration in today's health care environment, with an emphasis on the resultant adverse effects for patients. The first commentary describes a scenario in which many consultants were carefully considering a patient's case but were not communicating effectively with one another. The second commentary underscores how psychological safety can facilitate improved collaboration and error disclosure among teams. In the third part of the series, the author points out that although the practice of medicine is highly dependent on effective teamwork, medical culture continues to emphasize and even heroize the individual to its own detriment. The author suggests that further research is necessary to achieve optimal teamwork in medicine. A PSNet interview discussed the importance of leadership and teamwork in health care.
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.
Safe diagnosis is a complex challenge that requires multidisciplinary approaches to achieve lasting improvement. Effective feedback is a primary component of individual, team, and organizational learning. This commentary describes how creating pathways within an organization that enable physicians to provide and receive feedback about diagnostic performance can limit overdiagnosis and overuse.
Jones TS, Black IH, Robinson TN, et al. Anesthesiology. 2019;130:492-501.
Surgical fires, though uncommon, can result in serious harm. This review highlights three components to be managed in the operating room to prevent fires: an oxidizer, an ignition source, and a fuel. The authors provide recommendations to ensure each element is handled safely.
Anticoagulants are commonly prescribed medications that have high potential for harm if administered incorrectly. This review summarizes common errors at the prescribing, dispensing, and administration phases of direct oral anticoagulant therapy. The authors suggest team-based strategies—such as process assessment, policy development, and medication reconciliation—to prevent adverse drug events associated with direct oral anticoagulants.
Chrouser KL, Xu J, Hallbeck S, et al. Am J Surg. 2018;216:573-584.
Stressful clinician interactions can diminish the teamwork required to support safe care. This review describes a framework for guiding understanding of how behavioral and emotional responses can affect team behavior, performance, and patient outcomes in the surgical setting. The authors recommend areas of research required to fully understand the phenomenon.
Duffy JR, Culp S, Padrutt T. J Nurs Adm. 2018;48:361-367.
Prior research has shown that missed nursing care may in part result from reduced nurse staffing and is associated with adverse outcomes for patients. Using survey data from a sample of nurses at a single community hospital, researchers found that reduced nurse staffing, lower job satisfaction, and decreased satisfaction with teamwork were important factors related to missed nursing care.
Smith CD, Corbridge S, Dopp AL, et al. NAM Perspectives. Washington DC: National Academy of Medicine; 2018.
Teamwork can contribute to a healthy and respectful work environment. This discussion paper reviews evidence-based characteristics of high-functioning teams and barriers to their optimization in health care. Strategies to enhance teamwork and consequently clinician well-being include improvements in workflow, health information technologies, and financial models to train and sustain teams.
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