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Famolaro T, Hare R, Tapia A, Yount et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0004.

Ambulatory surgery centers harbor unique characteristics that affect safety culture. This analysis from the Agency for Healthcare Research and Quality (AHRQ) shares results of 235 ambulatory surgery centers (ASCs) participating in the Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey. Most respondents (92%) rated their organization as committed to learning and continuous improvement.
Brenner MJ, Boothman RC, Rushton CH, et al. Otolaryngol Clin North Am. 2021;55(1).
This three-part series offers an in-depth look into the core values of honesty, transparency, and trust. Part 1, Promoting Professionalism, introduces interventions to increase provider professionalism. Part 2, Communication and Transparency, describes the commitment to honesty and transparency across the continuum of the patient-provider relationship. Part 3, Health Professional Wellness, describes the impact of harm on providers and offers recommendations for restoring wellness and joy in work.
Flowerdew L, Tipping M. Emerg Med J. 2021;38(10):769-775.
This study sought to validate an emergency department (ED) safety questionnaire developed in the United States, and adapted for use in the UK. The survey was validated by 33 patient safety leads and used in a multi-center survey. Analysis highlighted risks and positive factors (e.g., positive safety culture) present in surveyed EDs.
Sotto KT, Burian BK, Brindle ME. J Am Coll Surg. 2021;Epub Oct 1.
The World Health Organization (WHO) Surgical Safety Checklist has been implemented in healthcare systems around the world. This systematic review and thematic analysis concluded that the surgical safety checklist positively impacts clinical outcomes (surgical outcomes and mortality), process measures, team dynamics, and communication, as well as safety culture. The authors note that the checklist was negatively associated with efficiency and workload; included studies often noted that checklist users felt the checklist slowed down processes within the operating room
Sosa T, Sitterding M, Dewan M, et al. Pediatrics. 2021;148(4):e2020034603.
Situational awareness during critical incidents is a key attribute of effective teams. This article describes the development of a situational awareness model, which included involving families and the interdisciplinary team in huddles, a shared mental model checklist, and an electronic health record (EHR) situational awareness navigator. Use of this new model decreased emergency transfers to the ICU and improved process measures, such as improved risk recognition before medical response team activation.
Morbidity and mortality (M&M) conferences are standard components of medical training programs yet medical residents underutilize incident reporting systems that feed into M&M conferences. To encourage incident reporting among residents, the Department of Orthopedic Surgery at Cedars Sinai Medical Center launched a web-based, real-time complication reporting platform to capture complications.
Grailey K, Leon-Villapalos C, Murray E, et al. BMJ Open. 2021;11(8):e046699.
Psychological safety enables staff to raise concerns, reduce mistakes and learn from errors. The majority of surveyed intensive care unit staff in three units within one trust in London reported feeling psychologically safe within their teams (e.g. being able to bring up problems). In a novel finding, this study identified potential negative consequences of psychological safety, including distraction and fatigue for team leaders.

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.

Gabrysz-Forget F, Zahabi S, Young M, et al. J Surg Educ. 2021;Epub Apr 24.
An essential part of resident training is error recovery- recognizing an error has occurred and strategizing how to correct the error to maximize patient safety. Through interviews with surgical residents, barriers and facilitators to experience error recovery were supervision, self, surgical context, and situation safeness. Focusing on these factors may enhance residents’ ability to develop their error recovery skills.
Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y, et al. Obstet Gynecol. 2021;138(2):229-235.
Patient misidentification errors can result in serious patient harm. The authors reviewed over 1.3 million electronic orders for inpatients at one New York hospital between 2016 and 2018 and found that wrong-patient order errors occurred more frequently on obstetric units than medical-surgical units. Medication errors were the largest source of order errors and commonly involved antibiotics and opioid and non-opioid analgesics.
Diabes MA, Ervin JN, Davis BS, et al. Ann Am Thorac Soc. 2021;18(6):1027-1033.
A key feature of safety culture is the psychological safety of all staff to feel empowered to speak up about errors or mistakes. In this study of intensive care unit clinicians, job strain, leader inclusiveness and perception of teamwork were associated with psychological safety. However, psychological safety was not associated with performance of either spontaneous breathing trials or lung-protective ventilation. Future research should focus on strategies to improve psychological safety in intensive care units.
Kruper A, Domeyer-Klenske A, Treat R, et al. J Surg Educ. 2021;78(3):1024-1034.
Physicians commonly experience adverse psychological outcomes after being involved in an adverse event. This mixed-methods study of health care providers in the Department of Obstetrics & Gynecology at one large academic hospital found that three-quarters of providers experienced symptoms of traumatic stress after involvement in an adverse event. Respondents reporting anxiety were more likely to be interested in peer-to-peer support programs, whereas those reporting symptoms of guilt preferred debriefing sessions.
Fischer CP, Bilimoria KY, Ghaferi AA. JAMA. 2021;326(2):179-180.
Rapid response teams (RRTs) are intended to quickly identify clinical deterioration and prevent intensive care unit transfer, cardiac arrest, or death. This article summarizes the evidence included in the AHRQ Making Healthcare Safer III report about the use of RRTs to decrease failure to rescue. Although utilization is widespread, the authors conclude that definitive evidence that RRTs are associated with reduced rates of failure to rescue is inconclusive. The authors note that evidence does support that RRTs are associated with reduced secondary outcomes, such as ICU transfer rate and cardiac arrest.
Wright MI, Polivka B, Abusalem S. AORN J. 2021;113(5):465-475.
Prior research identified variability in perioperative safety culture by provider type and experience. This study found that perioperative nurse engagement (e.g., energy, dedication, resilience) and perioperative nurse certification were significantly associated with self-reported safety culture in the operating room, but length of perioperative nurse experience was not.
Polancich S, Hall AG, Miltner RS, et al. J Healthc Qual. 2021;43(3):137-144.
The COVID-19 pandemic has disrupted many aspects of health care delivery, including how hospitals prevent common hospital-acquired conditions such as pressure injuries. Based on retrospective data, the authors of this study did not identify a longitudinal increase in hospital-acquired pressure injuries between March and July 2020. The authors discuss how prior organizational efforts to reduce hospital-acquired pressure injuries allowed their hospital to quickly adapt existing workflows and processes to respond to the COVID-19 pandemic.
Serou N, Husband AK, Forrest SP, et al. J Patient Saf. 2021;17(5):335-340.
Clinicians involved in a medical error may experience emotional distress, shame, and self-doubt. This qualitative study with medical and non-medical operating room staff at five hospitals in the United Kingdom explored support received after involvement in a patient safety incident. Participants were most likely to receive support from their peers after a patient safety incident, but highlighted a lack of institutional-level emotional and professional support and the need to cultivate an organizational culture where seeking support is not perceived as a sign of weakness.
Weinger MB. BMJ Qual Saf. 2021;30(8):613-617.
Checklists are widely used strategies for error reduction and improved communication. This editorial discusses the limitations of checklists for perioperative safety (i.e., when used in isolation or implemented incorrectly) and suggests that safety initiatives taking a systems-oriented approach and organizational buy-in can lead to both perioperative and general safety improvements.
Aaberg OR, Hall-Lord ML, Husebø SIE, et al. BMC Health Serv Res. 2021;21(1):114.
TeamSTEPPS is a patient safety intervention designed to improve teamwork and communication in healthcare settings. One Norwegian hospital utilized TeamSTEPPS to improve professional and organizational outcomes in the urology and gastrointestinal surgery ward. Twelve months after implementation, researchers observed sustained improvements in three patient safety culture dimensions and three teamwork dimensions. Further studies with larger same size and stronger study designs are warranted.

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.
Haidari E, Main EK, Cui X, et al. J Perinatol. 2021;41(5):961-969.
High levels of healthcare worker (HCW) burnout may be associated with lower levels of patient safety and quality. In June 2020, three months into the COVID-19 pandemic, 288 maternity and neonatal HCWs were asked about their perspectives on well-being and patient safety. Two-thirds of respondents reported symptoms of burnout and only one-third reported adequate organizational support to meet these challenges. Organizations are encouraged to implement programs to reduce burnout and support HCW well-being.