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Hennus MP, Young JQ, Hennessy M, et al. ATS Sch. 2021;2(3):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.

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 trigger tools.

Kjaergaard-Andersen G, Ibsgaard P, Paltved C, et al. Int J Health Care Qual. 2021;33(1):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in situ training identified several latent safety threats (e.g., equipment access, lack of closed-loop communication, out-of-date checklists) and these findings led to practice changes.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.
A woman with acute myeloid leukemia presented to the emergency department (ED) with shortness of breath after receiving chemotherapy. As laboratory test results showed acute kidney injury and suggested tumor lysis syndrome, the patient was started on emergent hemodialysis. She experienced worsening dyspnea and was emergently intubated and transferred to the intensive care unit. There, her blood pressure began to drop, and she died despite aggressive measures.
Shapiro FE, ed. Int Anesthesiol Clin. 2019;57:1-162.
This publication presents patient safety concepts for anesthesia practice, including decision aids to educate and empower patients about anesthesia choice, environmental hazards, interpersonal communication, team training, and use of technology and simulation as educational tools.
The Joint Commission. R3 Report. August 21, 2019;24:1-6.
Maternal safety in the United States is gaining momentum as a system-level patient safety concern. This report reviews the new Joint Commission Provision of Care, Treatment, and Services (PC) standards developed to improve the reliability of maternal care. Actions for improvement include patient risk assessment for conditions at admission and role-specific education for staff and providers who treat maternal patients regarding hemorrhage processes and procedures.
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.
Ruskin KJ; Stiegler MP; Rosenbaum SH; Oxford University Press; OUP.
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.
Hilton K; Anderson A.
This commentary describes how one health system worked to combat resistance to change associated with implementation of a checklist initiative. The success of the program was built on empowering team members to drive the process, clinician motivation to provide safe care, and engaging leadership. A PSNet interview with Lucian Leape discussed surgical safety checklists.
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.
Royal College of Surgeons of England; RCS.
Physical demands and technical complexities can affect surgical safety. This resource is designed to capture frontline perceptions of surgeons in the United Kingdom regarding concerning behaviors exhibited by their peers during practice to facilitate awareness of problems, motivate improvement, and enable learning.
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(2):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(4):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.