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.
Thompson KM, Swanson KM, Cox DL, et al. Mayo Clin Proc Innov Qual Outcomes. 2018;2:342-351.
This pre–post study found that medication administration errors decreased after the introduction of barcode medication administration, echoing prior studies. The authors conclude that use of barcode medication administration technology improves patient safety by reducing medication errors.
Law AC, Stevens JP, Hohmann S, et al. Crit Care Med. 2018;46:1563-1569.
… . This retrospective cohort study assessed the impact of a 2016 Massachusetts law that mandated minimum nursing ratios … care, which authors argue cannot be simply defined with a staffing ratio. A PSNet perspective and a WebM&M commentary further explore the safety risks of missed …
Thiels CA, Choudhry AJ, Ray-Zack MD, et al. JAMA Surg. 2017;153.
… Surgery … JAMA Surg … Review of malpractice litigation is a longstanding method for identifying patient safety vulnerabilities. Investigators reviewed a legal database for malpractice cases involving surgical … than half of cases implicated inadequate supervision as a contributing cause. As with previous research on closed …
Surgical site infections are an important type of health care–associated infection that safety efforts aim to prevent. This case-control study compared patients matched on age, gender, and elective procedure who developed surgical site infections with those who did not. Although investigators hypothesized that having additional personnel in the operating room would lead to higher likelihood of infection, after adjusting for patient- and procedure-related factors, they found this was not the case.
Thiels CA, Lal TM, Nienow JM, et al. Surgery. 2015;158:515-21.
Never events are devastating and preventable, and health care organizations are under increasing pressure to eliminate them completely. In this study, investigators evaluated all procedural never events using a validated human factors analysis method. They uncovered multiple underlying causes for each event. Cognitive failures were identified in about half the events. Preconditions, including environmental and technologic factors, were common contributors to events. Consistent with prior studies, the authors recommend enhancing communication among team members to augment safety. These results demonstrate the need to develop individual cognitive training interventions as well as systems approaches to address never events.
Moriarty JP, Schiebel NE, Johnson MG, et al. Int J Qual Health Care. 2014;26:49-57.
Although effectiveness of rapid response teams has traditionally been measured by using rates of cardiac arrests or intensive care unit transfers, this study advocates for using the AHRQ failure to rescue metric instead. Failure to rescue rates declined in the second year after implementation of the rapid response team in concert with increased utilization of the team.
Following successful bypass surgery and mitral valve repair, an elderly man with diabetes, hypertension, and end-stage renal disease continued to attend hemodialysis and other clinic visits regularly. Eight months later, he was admitted to the hospital with shaking chills, confusion, and a collection of pus in his chest. A surgical procedure to free the trapped lung also uncovered a surgical instrument from the previous surgery.
Naessens JM, Campbell CR, Shah ND, et al. Am J Med Qual. 2012;27:48-57.
… … Am J Med Qual … The epidemiology of adverse events on a population basis has been well studied, but how these data … been shown to experience more adverse events. An AHRQ WebM&M commentary discusses a case of a medication error occurring … ill patient with multiple underlying comorbidities. … Naessens JM, Campbell CR, Shah N, et al. Effect of illness …
Cima RR, Lackore KA, Nehring SA, et al. Surgery. 2011;150:943-9.
This study found that the Patient Safety Indicators lacked sensitivity and specificity for detecting postoperative adverse events, compared to the National Surgical Quality Improvement Program adverse event detection methodology.
Cima RR, Hale C, Kollengode A, et al. Arch Surg. 2010;145:641-6.
… Ill. : 1960) … Arch Surg … Wrong-site surgeries are a rare yet devastating complication for patients. Despite … , these events continue to occur. This study explored a less understood risk for wrong-site surgery by focusing on … the error rate was significantly reduced. Past AHRQ WebM&M commentaries have discussed the factors contributing to a …
Naessens JM, Campbell CR, Huddleston JM, et al. Int J Qual Health Care. 2009;21:301-7.
… results. For instance, only 6.2% of hospitalizations with a PSI also had a provider-reported event, and only 10.5% of … public reporting and performance comparisons. An AHRQ WebM&M commentary discusses the limitations of using PSIs for …