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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 52 Results
Lagoo J, Berry WR, Henrich N, et al. Jt Comm J Qual Patient Saf. 2020;46:314-320.
… Jt Comm J Qual Patient Saf … As part of a quality improvement initiative to enhance surgical … 20 physicians to understand potential areas of risk when a physician begins working in an unfamiliar setting.   … little to no onboarding when starting to practice in a new setting, which can limit their ability to provide safe …
Urbach DR, Dimick JB, Haynes AB, et al. BMJ. 2019;366:l4700.
… BMJ (Clinical research ed.) … BMJ … Checklists are a popular yet controversial strategy for improving the safety … debate the weaknesses and strengths of checklists through a discussion of the evidence . …
Berry WR, Edmondson L, Gibbons LR, et al. Health Aff (Millwood). 2018;37:1779-1786.
This study in the Health Affairs patient safety theme issue examines the implementation of surgical safety checklists. Checklists have been shown to improve patient outcomes in randomized control trials, but implementation studies have not consistently demonstrated similar improvements. In this statewide initiative, implementation of the checklist varied significantly among sites. Factors associated with more successful implementation included greater leadership participation, frontline engagement, and more frequent activities for all involved groups, including surgeons, nurses, technicians, and administrators. Sites that invested more funding and time also saw greater checklist implementation. The authors conclude that hospitals that participated more did better. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

Health Aff (Millwood). 2018;37(11):1723-1908.

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Gawande A. New Yorker. November 12, 2018.
… In this magazine article, Atul Gawande describes a range of frustrations physicians … of patient-centeredness, and alert fatigue . … Gawande A. New Yorker. November 12, 2018. … AGawandeAA A
Haas S, Gawande AA, Reynolds ME. JAMA. 2018;319:1765-1766.
Changes in organizational process and governance can create downstream conditions that result in failures. This commentary explored how system expansion affects safety. The authors highlight the need for leadership to use system data to plan for and manage the impact of the resultant infrastructure and patient population changes on care delivery.
Lagoo J, Berry WR, Miller K, et al. Ann Surg. 2019;270:84-90.
… 360-degree reviews, in which team members evaluate a range of professional attributes and behaviors, were … informing others, and considering others' suggestions had a significantly higher risk for malpractice claims. Surgeons … behaviors among surgeons could mitigate malpractice risk. A previous WebM&M commentary discussed patient complaints as …
Molina G, Berry WR, Lipsitz S, et al. Ann Surg. 2017;266:658-666.
Establishing a robust culture of safety, in which all staff feel free to voice concerns without fear of reprisal and leadership explicitly prioritizes safety, is crucial to safety improvement efforts. The most successful safety improvement programs have all explicitly prioritized enhancing safety culture. This study reports on the baseline results of a program that sought to improve surgical safety at hospitals in South Carolina. Safety culture was assessed among operating room personnel in 31 hospitals using a validated instrument. The investigators found a relatively robust association between better perceived safety culture and lower 30-day postoperative mortality. Studies in other clinical settings have found similar results. The hospitals involved in this study subsequently participated in a program to implement the Surgical Safety Checklist, which resulted in a significant improvement in mortality among participating hospitals compared to nonparticipating hospitals. A recent PSNet interview with Dr. Mary Dixon-Woods discussed the evolving concept of safety culture.
Duclos A, Peix JL, Piriou V, et al. Br J Surg. 2016;103:1804-1814.
Teamwork training programs have been implemented in a large variety of health care settings, and growing evidence suggests a positive impact. However, the effect of teamwork training programs in the context of surgical safety checklists is less clear. In this randomized study, researchers examined whether adding a team training program to surgical safety checklist utilization affected major surgical complications. All 31 hospitals in the study had implemented a surgical safety checklist a median of 19 months prior to the study. Team training was introduced across operating room teams in 16 hospitals randomized to the intervention arm. Investigators found a significant reduction in major adverse events in both the intervention and control arms. These results suggest that team training may not provide additional benefit when combined with a checklist. A past PSNet interview discussed challenges associated with implementing surgical safety checklists.
Tsai TC, Jha AK, Gawande AA, et al. Health Aff (Millwood). 2015;34:1304-1311.
… … Health Aff (Millwood) … Hospital leadership can play a critical role in improving safety and quality, as highlighted in a 2009 Joint Commission sentinel event alert . A prior review … in a past AHRQ WebM&M perspective . … Tsai TC, Jha AK, Gawande AA, Huckman RS, Bloom N, Sadun R. Hospital board and …
Gawande A. The New Yorker. May 2015
The overuse of medical care and its negative impact on personal health and finances is an emerging concern. This magazine article provides insights from a surgeon about how providing unnecessary care can contribute to patient harm and waste. Consequences of unneeded medical care include overtesting, overdiagnosis, and overtreatment. A previous AHRQ WebM&M perspective explored overuse as a patient safety problem.
Singer SJ, Jiang W, Huang LC, et al. Med Care Res Rev. 2015;72:298-323.
In this survey of surgical teams at South Carolina hospitals that were implementing the World Health Organization's surgical safety checklist, the majority of overall responses about patient safety were positive. However, there was wide variation between hospitals. In some hospitals surveyed, up to 57% of respondents reported that they would not feel safe being treated in their own operating room.
Kim RY, Kwakye G, Kwok AC, et al. JAMA Surg. 2015;150:473-9.
The World Health Organization's surgical safety checklist has been successfully implemented in multiple clinical settings. This study, conducted in Moldova, found that checklist usage remained high 2 years after initial implementation, with postoperative complication rates continuing to decline over that time period.
Arriaga AF, Gawande AA, Raemer D, et al. Ann Surg. 2014;259:403-10.
… programs have only included trainees. For this study, a malpractice insurer provided the financial and administrative resources necessary to develop a standardized OR simulation training curriculum that … care. Dr. David Gaba discussed simulation training in a recent AHRQ WebM&M interview . …

Neurosurg Focus. 2012;33(5):E1-E16.  

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