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.
Katz-Navon T, Naveh E. Health Care Manage Rev. 2022;47:e41-e49.
Balancing autonomy and supervision is an ongoing challenge in medical training. This study explored how residents’ networking with senior physicians influences advice-seeking behaviors and medical errors. Findings suggest that residents made fewer errors when they consulted with fewer senior physicians overall and consulted more frequently with focal senior physicians (i.e., physicians sought out by other residents frequently for consults).
Shao Q, Wang Y, Hou K, et al. J Adv Nurs. 2021;77:4005-4016.
Patient suicide in all settings is considered a never event. Nurses caring for the patient may experience negative psychological symptoms following inpatient suicide. This review identified five themes based on nurses’ psychological experiences: emotional experience, cognitive experience, coping strategies, self-reflection, and impact on self and practice. Hospital administrators should develop education and support programs to help nurses cope in the aftermath of inpatient suicide.
Abdallah W, Johnson C, Nitzl C, et al. J Health Organ Manag. 2019;33:695-713.
Organizations are encouraged to learn from failure. The authors surveyed hospital pharmacists to explore how organizational learnings relates to safety culture and found that the strongest contributors to safety culture were organizations prioritizing and supporting training and education.
This interview study examined multiple stakeholder perspectives, including patients, nurses, trainees, and attending physicians, on safety and dignity in health care settings. They cited the importance of safety culture and reported experiencing dilemmas in supporting safety and dignity in the hospital. The authors suggest that graduate medical education explicitly incorporate these concepts.
Prior research on the relationship between culture of safety and adverse events has produced conflicting results. Using culture of safety survey data from five long-term care facilities, researchers found an association between improved safety culture scores and a decreased risk of certain adverse events.
This validation study translated and adapted the Safety Attitudes Questionnaire, a safety culture measurement tool, into Gujarati and implemented it in four private hospitals in India. The authors found that safety culture was similar among the hospitals, even in comparisons between urban and rural settings.
Establishing an active learning climate, in which resident physicians are encouraged to ask questions, seek feedback, and reflect on their experiences, could actually lead to an increased likelihood of error if management's emphasis on safety is not appropriately calibrated.
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