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Patient Safety Network

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 - 4 of 4 Results
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    • Using simulation to improve systems-based practices.
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    • Gardner AK, Johnston MJ, Korndorffer JR, et al. The Joint Commission Journal on Quality and Patient Safety. 2017;43.
    Simulation has been advocated as a tactic to study team interaction and care activities. This review identified four key ways simulation-based techniques are used to identify factors that diminish safety in the perioperative setting and suggests that such interventions can be applied to improve the perioperative system.
    Using simulation to improve systems.
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    • Lundberg PW, Korndorffer JR. Surg Clin North Am. 2015;95:885-92.
    Safety approaches from aviation that can be applied to health care include teamwork and simulation. This review discusses the evolution of simulation use in both aviation and health care and highlights TeamSTEPPS as one way to apply simulated-based training to enhance individual, team, and system performance and reduce potential for patient harm.
    Retained foreign bodies: risk and outcomes at the national level.
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    • Al-Qurayshi ZH, Hauch AT, Slakey DP, et al. J Am Coll Surg. 2015;220:749-59.
    Leaving a surgical item behind after a procedure is a never event. This retrospective cross-sectional study sought to identify risk factors and outcomes of retained foreign bodies. Nearly one-third of incidents involving retained foreign objects were reported after gastrointestinal procedures. Risk of retained surgical items was highest in teaching hospitals.
    Using simulation to improve root cause analysis of adverse surgical outcomes.
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    • Slakey DP, Simms ER, Rennie K, et al. Int J Qual Health Care. 2014;26:144-50.
    Comparing the use of case simulation with root cause analysis for investigating adverse surgical outcomes, this study found that simulating the event identified more system errors and focused less on individual errors. This result supports wider implementation of simulation for evaluating adverse events.
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