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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 - 3 of 3 Results
Zakrison TL, Rosenbloom B, McFarlan A, et al. BMJ Qual Saf. 2016;25:929-936.
Trauma patients are among the most complex and critically ill patients admitted to the hospital, and as such they are particularly vulnerable to errors in their care. Prior studies have found that nearly 8% of deaths in patients with major trauma may be preventable, and other studies have identified poor quality handoffs as a possible contributor to harm in these patients. This mixed-methods study used chart review, focus groups, and interviews with nurses and physicians to examine the incidence and causes of errors in the transfer of trauma patients from the emergency department to the intensive care unit. The investigators found that 24% of patients had at least one missed injury, and the quality of information transfer was poor—clinical information in the trauma and intensive care unit teams' notes was discordant for nearly half of the patients. Lack of a standardized handoff process, poor communication between nurses and physicians, and variation in physicians' communication and teamwork skills were the main factors deemed responsible for the poor quality handoffs. A prior study found that human factors approaches can help standardize resuscitation and communication practices in the busy trauma environment.
Davis JS, Karmacharya J, Schulman C. J Patient Saf. 2012;8:151-2.
Describing a case of duplicate surgical site markings on a patient's legs, this article reveals how hospital protocol and medical record review prevented wrong-site surgery.