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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 - 11 of 11 Results
George BC, Bohnen JD, Williams RG, et al. Ann Surg. 2017;266:582-594.
Insufficient trainee supervision may lead to adverse events, but lack of autonomy may leave trainee physicians unprepared for independent practice. In this direct observation surgical education study, attending physicians rated readiness for independent practice and level of supervision for surgical trainees performing specific core procedures throughout the course of their training. At the end of training, 90% of trainees performed competently on average complexity patients, but this proportion dropped to less than 80% for the most complex cases. For about two-thirds of core procedures, surgical residents still had significant supervision in their last 6 months of training. The authors raise concerns about whether graduating residents have sufficient experience practicing independently to enter clinical practice. A previous PSNet perspective advocated for continued appropriate supervision to augment patient safety.
Davis A, Jones S, Crowell-Kuhnberg AM, et al. Surgery. 2017;161:1348-1356.
… Surgery … Communication failures in the operating room are a well-recognized threat to patient safety . Researchers … communication across seven operating room teams during a simulated emergency using a closed-loop communication … patterns varied by specialty and that the patient's clinical status influenced whether directed communication …
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 . …
Arriaga AF, Bader AM, Wong JM, et al. N Engl J Med. 2013;368:246-53.
… The New England journal of medicine … N Engl J Med … Surgical checklists have provided some of the most … were undergoing an operation. Atul Gawande (this study's senior author) describes the history and utility of …
Fuentealba I, Taylor GA. Pediatr Radiol. 2012;42:1305-15.
Imaging studies are often necessary to determine whether indwelling devices—such as vascular catheters or drainage tubes—have been correctly positioned. This study characterizes the frequency of diagnostic errors among radiologists in analyzing placement of indwelling devices in children.
Taylor GA, Callahan MJ, Rodriguez D, et al. Pediatr Radiol. 2006;36:331-7.
This study determined that abdominal CT scan represents a reliable method for evaluating patients with suspected appendicitis at an error rate of 3.1%. The majority of diagnostic errors attributed to this approach involved mostly false-positive interpretations. Based on analysis of imaging, clinical, and pathological data on more than 1200 patients with suspected appendicitis, investigators noted that presence of specific imaging findings (ie, greater than 6 mm appendix or fat stranding) were sensitive but not definitive for making the diagnosis. The authors suggest that the gold standard of diagnosis lies in the pathological findings, which should be used to understand true positive imaging findings. A similar study also tried to make the connection between clinical performance in diagnosis using pathological data.