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.
English M, Ogola M, Aluvaala J, et al. Arch Dis Child. 2021;106:326-332.
Health systems are encouraged to proactively identify patient safety risks. In the first of a two-part series, the authors draw on the Systems Engineering Initiative for Patient Safety (SEIPS) framework to discuss the strengths and challenge of a low-resource newborn unit from a systems perspective and SEIPS’ implications for patient safety.
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.
Jackson D, Sarki AM, Betteridge R, et al. Int J Nurs Stud. 2019;92:109-120.
Hospital-acquired pressure ulcers are considered never events and represent a significant source of patient harm. This systematic review and meta-analysis found a pooled incidence of 12% for pressure injuries related to the use of medical devices.
Mianda S, Voce A. BMC Health Serv Res. 2018;18:747.
Clinical leadership training and teamwork training both augment the safety of maternity care. This systematic review found that most leadership training in maternity settings used a work-based learning approach rather than simulation or classroom interventions. The authors emphasize the importance of tailoring leadership interventions to low- and middle-income countries, where this training is less common.
Sholomovich L, Magnezi R. Am J Infect Control. 2017;45:677-681.
Health care–associated infections (HAIs) are a significant source of preventable harm to patients. Although prior research has shown that clean hands are essential for reducing HAIs, health care institutions continue to struggle with hand hygiene compliance. In this study, investigators surveyed 400 nurses at a pediatric hospital and found a positive correlation between psychological safety and belief in personal responsibility for preventing the spread of infection. The authors argue that improving the psychological safety of staff may augment the response to hand hygiene initiatives.
Zohar D, Werber YT, Marom R, et al. BMJ Qual Saf. 2017;26:653-662.
This randomized controlled trial randomized head nurses in inpatient settings to either receive individual feedback based on questionnaires from frontline nurses followed by goal-setting, versus a summary report of feedback at the end of the intervention. In the intervention group, patient care messages increased and blaming decreased, demonstrating that a brief and feasible intervention can enhance safety culture.
Zarei E, Khakzad N, Reniers G, et al. Saf Sci. 2016;89:1-10.
Burnout among nurses has been linked to safety hazards. This cross-sectional study found that burnout among nurses is associated with a worse safety climate and higher levels of stress. A recent Annual Perspective discussed the relationship between safety and burnout.
Drach-Zahavy A, Hadid N. J Adv Nurs. 2015;71:1135-45.
This prospective study examined 200 hospital nurse handovers. Documentation was missing in nearly half of patients' files, and dosage discrepancies were identified in 23% of cases. Use of strategies that emphasized the input and interaction of the incoming team—such as face-to-face verbal updates with questions—were associated with fewer treatment errors.
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