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Redley B, Douglas T, Hoon L, et al. J Adv Nurs. 2022;Epub Jul 7.
Frontline care providers such as nurses play an important role in reducing preventable harm. This study used qualitative methods (direct observation and participatory workshops) to explore nurses’ experiences implementing harm prevention practices when admitting an older adult to the hospital. Researchers identified barriers (e.g., lack of resources, information gaps) and enablers (e.g., teamwork, reminders) to harm prevention during the admission process.

A psychologically safe environment for healthcare teams is desirable for optimal team performance, team member well-being, and favorable patient safety outcomes. This piece explores facilitators of and barriers to psychological safety across healthcare settings. Future research directions examining psychological safety in healthcare are discussed.

Hennus MP, Young JQ, Hennessy M, et al. ATS Sch. 2021;2:397-414.
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.
De Brún A, Anjara S, Cunningham U, et al. Int J Environ Res Public Health. 2020;17:8673.
Leadership has an important role in promoting a culture of safety and enabling necessary changes to enhance patient safety. This article summarizes the design, pilot testing, and refinement of the Collective Leadership for Safety Culture (Co-Lead) program, which offers a systematic approach to developing collective leadership behaviors to promote effective teamwork and enhance safety culture.
Bacon CT, McCoy TP, Henshaw DS. J Nurs Adm. 2021;51(1) :12-18.
Lack of communication and interpersonal dynamics can contribute to failure to rescue. This study surveyed 262 surgical staff about perceived safety climate, but the authors did not find an association between organizational safety culture and failure to rescue or inpatient mortality.  
Kjaergaard-Andersen G, Ibsgaard P, Paltved C, et al. Int J Health Care Qual. 2021;33: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.  
Britton CR, Hayman G, Stroud N. J Perioper Pract. 2021;31:44-50.
The COVID-19 pandemic has highlighted the crucial role that team and human factors play in healthcare delivery. This article describes the impact of a human factors education and training program focused on non-technical skills and teamwork (the ONSeT project) – on operating room teams during the pandemic. Results indicate that the project improved team functioning and team leader responsiveness.
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
JN Learning. 2020.
Disruptive behavior is a recognized deterrent to safe communication, sharing of concerns and teamwork. This educational program highlights a study that measured the impact of unprofessional physician behavior on patient care and features Dr. William Cooper and Dr. Gerald Hickson as speakers.
McHugh SK, Lawton R, O'Hara JK, et al. BMJ Qual Saf. 2020;29:672-683.
Team reflexivity represents the way individuals and team members collectively reflect on actions and behaviors, and the context in which these actions occur.  This systematic review identified 15 studies describing the use of team reflexivity within healthcare teams. Included interventions, most commonly simulation training  and video-reflexive ethnography, focused on the use of reflexivity to improve teamwork and communication. However, methodological limitations of included studies precluded the authors from drawing conclusions around the impact of team reflexivity alone on teamwork and communication.
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.
Loftus TJ, Hall DJ, Malaty JZ, et al. Acad Psychiatry. 2019;43:581-584.
Resident physicians complete an annual evaluation of their training program, which includes questions on their program's culture of safety. Conducted among residency programs at a single academic medical center, this analysis found that residents in programs that emphasized safety culture had higher rates of passing their board certification exams on the first attempt.
Hoonakker PLT, Wooldridge AR, Hose B-Z, et al. Intern Emerg Med. 2019;14:797-805.
Patient acuity and the need for interdisciplinary collaboration contribute to patient safety issues in trauma care. This qualitative study explored perceptions of handoff safety in pediatric trauma patients and found a high potential for information loss due to the rapidity of handoffs and the multiple disciplines involved.