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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 26 Results
O'Connor K, Neff DM, Pitman S. Eur Psychiatry. 2018;53:74-99.
Clinician burnout has been associated with decreased job satisfaction. Burnout may also be detrimental to patient safety. This systematic review and meta-analysis found high rates of burnout among mental health professionals. The authors recommend strategies to address burnout including promoting professional autonomy, developing teamwork, and providing quality clinical supervision.
Welp A, Meier LL, Manser T. Crit Care. 2016;20:110.
Emotional exhaustion is a component of burnout—a critical patient safety issue. Teamwork promotes resilience and thus may protect against burnout and promote patient safety. However, it is unclear how teamwork, burnout, and patient safety interact in a safety culture. This prospective study of critical care interprofessional teams found that clinicians' emotional exhaustion affects teamwork, which leads to worsening clinician reports of patient safety. The authors suggest addressing clinicians' emotional exhaustion prior to team training in order to best augment patient safety in the intensive care unit. A PSNet interview discusses strategies to enhance clinicians' emotional resilience.
Berry JC, Davis JT, Bartman T, et al. J Patient Saf. 2020;16:130-136.
A culture of safety is a fundamental component of patient safety. Several validated survey tools are available to measure hospital safety and teamwork climates, including the AHRQ Surveys on Patient Safety Culture and the Safety Attitudes Questionnaire (SAQ). Improvements in SAQ scores have been previously linked to reductions in specific safety outcomes, such as maternal and fetal adverse events in an obstetric ward. This study explored SAQ results and outcomes across all inpatient and outpatient care units in a large academic health system. Beginning in 2009, Nationwide Children's Hospital in Ohio introduced a comprehensive patient safety and high reliability program that included numerous quality improvement activities and extensive training in error prevention for each of their approximately 10,000 employees. Over the course of 4 years, SAQ scores improved while all-hospital harm, serious safety events, and severity-adjusted hospital mortality all decreased significantly. A prior WebM&M interview with J. Bryan Sexton, the primary author of the SAQ instrument, discussed the relationship between culture and safety.
O'Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.
Interdisciplinary teamwork is a primary driver of safety culture, and lack of teamwork has been linked to poor clinical outcomes in surgery and the emergency department. Creating high-functioning teams is challenging in inpatient medicine wards, due to numerous barriers including variability in physician and nurse schedules and communication styles. This study, which built on prior work by the same authors, sought to improve interdisciplinary teamwork at a teaching hospital by creating structured, daily rounds where the entire care team discussed patients. The intervention resulted in a significant decrease in preventable adverse events compared with historical and concurrent controls. The accompanying editorial notes that the hospital where this study was conducted had several structural features that also encouraged interdisciplinary communication (such as an electronic health record), and that structured interdisciplinary rounds could have an even larger impact at hospitals lacking such features.

Vincent C. West Sussex, UK: Wiley-Blackwell; 2010. ISBN: 9781405192217.  

Dr. Charles Vincent, a psychologist by training, is unquestionably one of the founders of the modern patient safety movement and continues to publish groundbreaking research in the field. This essential textbook discusses the evolution of patient safety efforts, outlines current medical error reduction strategies, and emphasizes practical examples of initiatives to improve patient safety. Dr. Vincent was interviewed for AHRQ WebM&M in 2012, and discussed his career as well as the current state of patient safety in the United Kingdom.
Pronovost P, Vohr E. New York, NY: Hudson Street Press; 2010. ISBN: 9781594630644.
Over the past decade, Johns Hopkins intensivist Dr. Peter Pronovost has emerged as the world's most influential patient safety researcher. In this book, written with Eric Vohr, Pronovost describes how his work was inspired by two deaths from medical mistakes: of young Josie King at Johns Hopkins Hospital (chronicled by her mother Sorrel in another book) and of his own father. The meat of the volume is a detailed chronicle of Pronovost's journey from neophyte faculty member to internationally acclaimed researcher and change agent. In earnest and plainspoken prose, he describes the inside story of interventions and studies that have transformed the safety world: the Comprehensive Unit-Based Safety Program (CUSP), the use of ICU goal cards, and most importantly, the use of checklists to reduce central line infections in more than 100 Michigan ICUs, a story also recently described by Dr. Atul Gawande in The Checklist Manifesto. Dr. Pronovost was the subject of an AHRQ WebM&M interview in 2005.
Kim MM, Barnato AE, Angus DC, et al. Arch Intern Med. 2010;170:369-76.
Efforts to improve the care of complex patients in intensive care units (ICUs) focus on many factors, including unit-based initiatives. This retrospective study evaluated the relationship between daily multidisciplinary rounds and 30-day mortality. Investigators discovered that the presence of daily rounds was associated with lower mortality among medical ICU patients. In addition, the survival benefits observed with intensivist staffing were in part explained by the presence of multidisciplinary care models. A related commentary [see link below] discusses this study's findings and the concept of health engineering as a systems science to study how we optimize staffing and patient outcomes in the ICU.

Croskerry P, Cosby KS, Schenkel SM, Wears RL, eds. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. ISBN: 9780781777278.

The pace, diversity, and scope of an emergency department (ED) create a setting particularly prone to medical error. This comprehensive textbook provides important information on developing and advancing patient safety in emergency medicine, including relevant content on the ED setting, medical errors, organizational approaches to safety, teamwork, education, and human performance. The target audience is primarily emergency physicians and administrators but likely would extend to other allied health professionals and patient safety advocates. This textbook sets a foundation for the establishment of patient safety practices within emergency medicine.
Haynes AB, Weiser TG, Berry WR, et al. N Engl J Med. 2009;360:491-9.
Success in patient safety is generally measured in incremental steps rather than giant leaps, but this pioneering study certainly represents the latter. Eight hospitals with widely differing resources and patient populations were required to implement a checklist based on the World Health Organization's Safe Surgery Saves Lives guidelines. The 19-item checklist focused on three key junctures: sign in (before induction of anesthesia), timeout (immediately before skin incision), and sign out (when the patient is ready to leave the operating room). It also included specific measures to improve teamwork and reduce the risk of surgical site infection. Checklist implementation resulted in significant reductions in mortality and inpatient complications. Checklists have already proved to be a powerful intervention in improving patient safety. This study's senior author, Atul Gawande, wrote about the success of checklists in preventing central-line associated bloodstream infections in a 2007 New Yorker article.
Mazzocco K, Petitti DB, Fong KT, et al. Am J Surg. 2009;197:678-85.
Direct observation of teamwork during surgical procedures revealed that poor teamwork was associated with higher rates of postoperative complications and overall mortality, even after adjusting for preoperative risk. Though suboptimal teamwork is a recognized problem in the operating room, this study is one of the first to directly link team behavior to patient outcomes. One method of improving teamwork, crew resource management training, has been extensively evaluated in a variety of clinical settings. A near miss resulting from poor teamwork is illustrated in a recent AHRQ WebM&M commentary.
Pronovost PJ, Berenholtz SM, Goeschel C, et al. J Crit Care. 2008;23:207-212.
The Keystone ICU project is a landmark achievement in patient safety. This project, funded by AHRQ, represented a collaboration between patient safety experts at Johns Hopkins University and the Michigan Hospital Association to improve patient safety in 99 intensive care units (ICUs). This article discusses implementation of the comprehensive unit-based safety program, which was the cornerstone of the project, and provides detailed information on the organizational change model used as well as the interventions that were implemented. The remarkable successes achieved by this project include near-elimination of catheter-related bloodstream infections and a significant improvement in the safety culture in participating ICUs. The project's principal investigator, Dr. Peter Pronovost, was interviewed by AHRQ WebM&M near the project's conclusion in 2005.
Davenport DL, Henderson WG, Mosca CL, et al. J Am Coll Surg. 2007;205:778-84.
Hospitals are urged to measure their safety culture through the use of one of several validated surveys that assess teamwork and organizational attitudes toward safety. Although several such surveys exist, evidence linking survey responses to improved patient outcomes is lacking. This AHRQ-funded study assessed the relationship between safety culture (as measured by the Safety Attitudes Questionnaire) and clinical outcomes in surgical patients, and found no clear relationship between perceived safety culture and risk-adjusted morbidity and mortality. However, reduced morbidity correlated with higher ratings of communication within surgical teams. This finding supports prior research that implicated communication failures as a cause of safety problems in surgery.
Makary MA, Mukherjee A, Sexton B, et al. J Am Coll Surg. 2007;204:236-43.
Although wrong-site surgeries are rare, they have devastating consequences for patients and are often a harbinger of serious safety problems within an institution. The Joint Commission's Universal Protocol for prevention of wrong-site surgeries requires performing a "time out" before beginning surgery to ensure that all operating room personnel are familiar with the patient, the procedure, their role, and how to respond to complications. In this study, operating room personnel were surveyed regarding their perception of the risk of wrong-site surgery before and after institution of timeouts. Respondents felt teamwork improved and the overall risk for wrong-site surgery decreased after implementing the protocol. An Agency for Healthcare Research and Quality (AHRQ) WebM&M commentary discusses the factors contributing to a near-miss wrong-site surgery.
Makary MA, Sexton B, Freischlag JA, et al. J Am Coll Surg. 2006;202:746-52.
This Agency for Healthcare Research and Quality (AHRQ)–supported study advocates for the use of the Safety Attitudes Questionnaire (SAQ) as a validated method to evaluate teamwork, communication, and the quality of collaborative care. Investigators surveyed more than 2000 surgeons, anesthesiologists, and operating room nurses in 60 hospitals to demonstrate the substantial differences in self-reported teamwork ratings. For instance, physicians rated teamwork as good, whereas nurses rated it as mediocre. These findings mirror a past study comparing teamwork perceptions in the operating room with those in a cockpit. As teamwork remains a critical component of patient safety, the authors propose that a better understanding of these existing disconnects can drive future improvement efforts. The same authors recently described using the SAQ as a tool to evaluate safety culture in surgical settings.
Sexton JB, Helmreich RL, Neilands TB, et al. BMC Health Serv Res. 2006;6:44.
This AHRQ-supported study discusses one of the best-studied tools to measure and assess patient safety culture. Investigators present the cumulative findings from administering the Safety Attitude Questionnaire (SAQ) to more than 10,000 providers in 203 clinical areas and in 3 countries. The domains that encompass provider attitudes include teamwork climate, safety climate, perceptions of management, job satisfaction, working conditions, and stress recognition. The authors describe their findings with a goal that their tool will allow health care organizations to measure safety attitudes and compare themselves across domains to others. A past study described the results of using such a tool in an academic medical center.
Sexton JB. BMJ. 2002;320.
This study describes self-reported perceptions of teamwork among operating room and intensive care unit staff as well as those of an airline cockpit crew. In the medical setting, investigators discovered tremendous variation in teamwork perceptions that followed traditional hierarchies. While surgical attendings and residents rated teamwork high, anesthesiology attendings rated it lower, as did surgical nurses and anesthesia residents in decreasing order. The authors also note that discussing errors seems to be a greater challenge in medicine than in aviation, which may derive from the fact that aviation participants acknowledged that fatigue and stress negatively impact job performance. While the findings draw only from survey results and make no connection to actual errors in practice, they do generate support for a safety culture in medicine similar to that of the aviation field.
Weinger MB; Englund CE.
This review discusses the important role ergonomic and human factors should play in ensuring safe anesthetic care, drawing on literature from non-health care settings. The authors begin by discussing errors in anesthesia and the opportunities created for such errors by the inevitable nature of the job. They continue by presenting a framework for the contributing factors, which include the work environment (eg, noise, lighting, temperature), the human component (eg, team factors, fatigue, workload), and the equipment and system component (eg, alarms, automation). The authors advocate for greater attention to these contributing factors and further study based on the experiences of other high-risk, error-prone industries.
Sachs BP. JAMA. 2005;294:833-840.
Part of a series in JAMA entitled Clinical Crossroads, this case study discusses the unfortunate events surrounding a 38-year-old woman’s presentation to a labor and delivery unit. The case details a seemingly routine full-term pregnancy that rapidly evolved into a course of complications, ultimately leading to a fetal death, a hysterectomy, and a prolonged hospital course. The discussion shares the experience through the eyes of the patient, her husband, and the primary obstetrician. Further exploration of the case identified several specific factors and broader systems issues that contributed to the events. The author shares how this particular institution responded with overarching changes, including a greater emphasis on teamwork, communication, and appropriate staffing of labor and delivery units to promote safety.
Gandhi TK, Graydon-Baker E, Barnes JN, et al. Jt Comm J Qual Saf. 2003;29:383-90.
Drawing from their experiences at Brigham and Women’s Hospital in Boston, the authors discuss development of a patient safety team, including the key players and their roles, how to effectively integrate the team into preexisting committees, and how to establish clear goals and initiatives. They conclude by emphasizing the importance of a commitment from organizational leadership.
Hillman K, Chen J, Cretikos M, et al. Lancet. 2005;365:2091-7.
This study examined the impact of medical emergency teams (METs), also known as rapid response teams (RRTs), on cardiac arrests, transfers to an intensive care unit (ICU), and deaths. The 23-hospital Australian study evaluated the availability of METs at designated hospitals and collected data prior to and during the six months following implementation. Findings suggested more calls for the emergency team but no difference in primary or secondary outcomes. However, the authors point out that even at hospitals with METs in place, inadequate utilization occurred for patients who met clinical criteria. They conclude that despite similar outcomes in both hospital groups, system-based interventions can support a focus on improved monitoring of patients and appropriate response by clinicians.