The PSNet Collection

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.

How surgical trainees handle catastrophic errors: a qualitative study.

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Balogun JA, Bramall AN, Bernstein M. J Surg Educ. 2015;72:1179-84.

According to this qualitative study, surgery resident physicians perceive that catastrophic errors result from system problems and provide lessons for future practice. Participants did not feel comfortable discussing errors with staff and reported work culture as a barrier to asking for support, demonstrating the need to teach trainees about error disclosure.

Wrong-site craniotomy: analysis of 35 cases and systems for prevention.

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Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-73.

This study found that communication breakdowns, inadequate preoperative checks, technical factors, and human error were the primary categories identified in assessing the root causes of wrong-site craniotomy. The authors suggest that the events were preventable had proper compliance with protocols taken place.

Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases.

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Stone S, Bernstein M. Neurosurgery. 2007;60:1075-80; discussion 1080-2.

This analysis of cases performed by a single neurosurgeon found that errors occurred frequently, most were preventable, and 2.7% of patients experienced an adverse clinical outcome due to error.

Is consent required for publication of medical errors?

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Weisbaum K, Hyland S, Bernstein M. Healthc Q. 2005;8:66-9.

The authors argue that, under certain conditions, publication of patient information without consent can be justified for the purposes of learning from medical errors.

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