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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 - 7 of 7 Results

Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022.

Surgical equipment sterilization can be hampered by equipment design, production pressures, process complexity and policy misalignment. This report examines a case of unclean surgical instrument use. It recommends external sterile service assessment and competency review as steps toward improving the reliability of instrument decontamination processes in the National Health Service.
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, care standardization,teamwork, unit-based safety initiatives, and...

Kuhn CM, Newton RC, Damewood MD, et al, on behalf of the CLER Evaluation Committee, the CLER Operative and Procedural Subprotocol National Advisory Group, and the CLER Program. Chicago, IL: Accreditation Council for Graduate Medical Education; February 2021. ISBN: 9781945365386.

The teaching hospital environment can produce clinician behaviors and mindsets that persist throughout a medical career. This report from a clinical learning environment assessment program shares insights gathered during walking rounds specific to perioperative care and general medicine. The report concluded that residents did not actively report problems and rarely participated in event investigations.
London, UK: Royal College of Surgeons of England; 2019.
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.
Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Royal College of Surgeons of Edinburgh; July 31, 2017.
Surgical training is demanding and can result in burnout. This publication explores deficiencies in surgical training that can contribute to a stressful work environment and diminish the safety of care delivery. The report recommends changes to improve work climate and reduce the potential for error, including establishing a strong team culture and promoting human factors training.

McCulloch P, Morgan L, Flynn L, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.

This publication reports five British hospitals' experiences with teamwork interventions in surgical teams. Although teamwork training alone improved how teams functioned, it did not always enhance clinical performance. The investigators found that integrated training that combines technical and social improvements, such as Lean, resulted in more effective improvements.