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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 218 Results
Rose SC, Ashari NA, Davies JM, et al. CJEM. 2022;24:695-701.
Debriefing is used to enhance individual and team communication and to facilitate real-time learning opportunities after a critical event. This study evaluated a charge nurse-facilitated clinical debriefing program used in Emergency Departments (EDs) in Alberta, Canada. Qualitative analyses identified several themes underscoring the impact of the debriefing program – the impacts on clinical practice and patient care, impacts on psychological safety and teamwork, stress management, and the emotional acknowledgement after critical events – and barriers to debriefing.
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.
Schilling S, Armaou M, Morrison Z, et al. PLoS ONE. 2022;17:e0272942.
Effective teamwork is critical in acute and intensive care settings. This systematic review of reviews and thematic analysis identified four key factors that frame the evidence on interprofessional teams in acute and intensive care settings – (1) team internal procedures and dynamics, such as cohesion, organizational culture, and leadership influence; (2) communicative processes; (3) organizational and team-extrinsic influences, such as team composition, hierarchy, and interprofessional dynamics, and; (4) team outcomes, including both patient and staff outcomes.
Hennus MP, Young JQ, Hennessy M, et al. ATS Sch. 2021;2:397-414.
The surge of patients during the COVID-19 pandemic forced the redeployment of non-intensive care certified staff into intensive care units (ICU). This study surveyed both intensive care (IC)-certified and non-IC-certified healthcare providers who were working in ICUs at the beginning of the pandemic. Qualitative synthesis identified five themes related to supervision; quality and safety of care; collaboration, communication, and climate; recruitment, scheduling and team composition, and; organization and facilities. The authors provide recommendations for future deployments.
Curated Libraries
September 13, 2021
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, collaborative initiatives, teamwork, and trigger tools.
Kjaergaard-Andersen G, Ibsgaard P, Paltved C, et al. Int J Health Care Qual. 2021;33:mzaa148.
Simulation training is used by hospitals to improve patient care. This study describes the experience of one Danish hospital shifting from simulation training at external centers to in situ training. The shift to in situ training identified several latent safety threats (e.g., equipment access, lack of closed-loop communication, out-of-date checklists) and these findings led to practice changes.  
Gavin N, Romney M-LS, Lema PC, et al. BMJ Leader. 2021;5:39-41.
Developed in the field of aviation, crew resource management (CRM) is used to teach teamwork and effective communication and has been used extensively in patient safety improvement efforts. This commentary describes four New York metropolitan area emergency departments’ experience applying (CRM) principles at an organizational level in responding to the current COVID-19 pandemic as well as future crises.
Trinchero E, Kominis G, Dudau A, et al. Public Manag Rev. 2020;22.
Employing a mixed-methods approach, this study found that teamwork (directly and indirectly) positively impacted professionals’ safety behavior. Teamwork indirectly impacted safety behavior by increasing individual’s positive psychological capital, thereby increasing their self-efficacy and resilience. These findings emphasize the role of hospital leadership and middle management in creating an organizational culture of safety
Ricciardi R, Shofer M. J Nurs Care Qual. 2019;34:1-3.
This commentary discusses the importance of the nurse-patient relationship and engagement with patients and their family members to improve patient safety practices. The article also provides an overview of AHRQ resources intended to facilitate engagement between providers and their patients and family members.
Wright B, Faulkner N, Bragge P, et al. Diagnosis (Berl). 2019;6:325-334.
The hectic pace of emergency care detracts from reliability. This review examined the literature on evidence, practice, and patient perspectives regarding diagnostic error in the emergency room. A WebM&M commentary discussed an incident involving a diagnostic delay in the emergency department.
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.
Kaur AP, Levinson AT, Monteiro JFG, et al. J Crit Care. 2019;52:16-21.
The second victim effect has been used to describe the emotional impact that providers may experience when involved in a medical error, adverse event, or unanticipated patient outcome. In this survey study, researchers found that members of a critical care society frequently admitted to experiencing negative emotions such as blame and guilt when responding to questions involving scenarios of different types of errors. Nearly 70% of respondents suggested that team debriefings and talking with colleagues could help mitigate the second victim effect.
Rönnerhag M, Severinsson E, Haruna M, et al. J Adv Nurs. 2019;75:585-593.
Inadequate communication in obstetrics can compromise safety. In this qualitative study, researchers conducted focus groups of multidisciplinary teams including obstetricians, midwives, and nurses working in a single maternity ward to examine their perceptions of adverse events during childbirth. Analysis of data collected suggests that support for high-quality interprofessional teamwork is important for safe maternity 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.
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.
Pettis AM. AORN J. 2018;108:644-650.
Failure to adhere to evidenced-based practices can result in patient harm. This article explores how high reliability concepts can support the reliable use of best practices to prevent surgical site infections. The authors suggest a framework focused on team engagement, education, implementation, and evaluation to encourage the use of evidence-based practice on the front line.
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.
Dietz AS, Salas E, Pronovost PJ, et al. Crit Care Med. 2018;46:1898-1905.
This study aimed to validate a behavioral marker as a measure of teamwork, specifically in the intensive care unit setting. Researchers found that it was difficult to establish interrater reliability for teamwork when observing behaviors and conclude that assessment of teamwork remains complex in the context of patient safety research.