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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 - 13 of 13 Results
Douglas RN, Stephens LS, Posner KL, et al. Br J Anaesth. 2021;127:470-478.
Effective communication among providers helps ensure patient safety. Through analysis of perioperative malpractice claims using the Anesthesia Closed Claims Project database, researchers found that communication failures contributed to 43% of total claims, with the majority between the anesthesiologist/anesthesia team and the surgeon/surgery team. Methods to improve perioperative communication are discussed.
Weinger MB, Banerjee A, Burden AR, et al. Anesthesiology. 2017;127:475-489.
Simulation training has been increasingly employed in health care, largely due to its success in the aviation industry. Prior research suggests that simulation programs can lead to improved knowledge, skills, and behaviors among health care professionals. In this study, researchers video recorded 263 board-certified anesthesiologists performing two mannequin-based simulated emergencies to determine whether this type of simulation is a reliable way to evaluate competency. Blinded anesthesiologists then evaluated the recordings using standardized rating tools to assess the percentage of critical performance elements carried out and to provide an overall rating of participants' technical and nontechnical skills. In 284 of the simulated emergencies, the participating anesthesiologists completed 81% of the critical performance elements successfully. About 25% of the participants were given low overall ratings. The authors conclude that assessing anesthesiologists' skills in simulated medical emergencies can help identify opportunities for improvement and better inform continuing medical education initiatives. A past PSNet perspective discussed the literature on health care simulation.
Schulz CM, Burden A, Posner KL, et al. Anesthesiology. 2017;127:326-337.
Failure to maintain situational awareness can adversely impact patient safety. In this closed claims analysis of anesthesia malpractice claims for death or brain damage, researchers found that situational awareness errors on the part of the anesthesiologist contributed to death or brain damage in 74% of claims.
Kiesewetter I, Schulz CM, Bausewein C, et al. BMC Palliat Care. 2016;15:75.
Adverse events in palliative care differ from those in other environments. This qualitative interview study of patients who received palliative care identified errors specific to this setting, including deviation from a patient's advance directive and error in prognosis. A recent WebM&M commentary discussed challenges to implementing advance directives.
Schulz CM, Krautheim V, Hackemann A, et al. BMC Anesthesiol. 2016;16:4.
This retrospective review of anesthesia and critical care cases in the German incident reporting system found that errors in situational awareness contributed to 81.5% of events. This study includes detailed examples and analyses of these errors, providing useful insights into lapses in situational awareness.
WebM&M Case April 1, 2015
… Anesthesiologist Group Health Cooperative Seattle, WA … Karen B. Domino, MD, MPH … Professor & Vice Chair for … 13, 2011. [Available at] 7. Mehta SP, Bhananker SM, Posner KL, Domino KB. Operating room fires: a closed claims … ECRI Institute). … Sonya … Karen … Mehta … Domino … P … M … Sonya P Mehta … Karen M Domino
Dietz I, Plog A, Jox RJ, et al. J Palliat Med. 2014;17:331-7.
This survey of palliative care workers in Germany sought to identify common medical errors in this setting. The majority of errors were related to communication, system failures, and medication administration, including opioid overdose.
Davies JM, Posner KL, Lee LA, et al. Anesthesiology. 2009;110:131-139.
The use of closed claims data to identify risk exposures, highlight safety issues, and drive improvement changes have been applied in ambulatory care, surgery, emergency medicine, and obstetrics. This study uses a previously described database to compare liability profiles in obstetric anesthesia before and after 1990. Investigators found that while the proportion of maternal death and newborn death or brain damage claims decreased in recent years (though still a leading cause), maternal nerve injury and back pain increased in later claims. Delays in anesthesia care, substandard care, and poor communication between the obstetrician and anesthesiologist are identified as preventable causes of newborn injury.
Griffen FD, Stephens LS, Alexander JB, et al. Transactions of the .. Meeting of the American Surgical Association. 2008;126.
Disruptive behaviors are a growing concern in patient safety and system-level solutions remain a challenge. This study adds to those concerns by finding that failures in behavioral practice occurred in nearly 80% of examined closed cases with poor communication accounting for the majority of patient complications.
Bhananker SM, Posner KL, Cheney FW, et al. Anesthesiology. 2006;104:228-234.
Using closed malpractice claims from a previously described database, this study discovered significant patient injury associated with monitored anesthesia care (MAC) and a liability profile similar to that of general anesthesia. Investigators performed a detailed analysis of more than 120 MAC claims, compared them with those of general and regional anesthesia, and report on the claim characteristics. MAC claims involved older and more ill patients, with respiratory depression being the most frequent occurrence leading to patient injuries. The authors conclude that more than half of the claims would be preventable with improved monitoring strategies.