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.
This study examined variation in operative technical skills among patients undergoing colorectal and non-colorectal procedures and the association with patient outcomes. Higher technical skills were significantly associated with lower rates of complications, unplanned reoperations, and death or serious morbidity. The findings suggest that this skill variation accounts for more than 25% of the variation in patient outcomes.
Zhang LM, Ellis RJ, Ma M, et al. JAMA. 2020;323:2093-2095.
In this survey of 6,264 US general surgery residents, 70% reported experiencing at least one bullying behavior during surgical training and 18% reported frequent bullying. The most common types of bullying behavior were repeated reminders of mistakes, being shouted at, withholding of important information, persistent criticism, and hostility. Women and racial/ethnic minorities reported more frequent bullying. Residents reporting frequent bullying had higher rates of burnout, suicidal thoughts, and thoughts of leaving surgical training.
Prachand VN, Milner R, Angelos P, et al. J Am Coll Surg. 2020;231:281-288.
Physicians may be faced with difficult decisions regarding potential limits to patient access to care during the COVID-19 pandemic in order to preserve resources to meet the medical needs of patients diagnosed with COVID-19. This article describes a scoring system incorporating resource limitations and COVID-19 transmission risk to facilitate decision-making and triage for medically-necessary, time-sensitive procedures while balancing patient risk and public health concerns.
Hewitt DB, Ellis RJ, Chung JW, et al. Ann Surg. 2021;274:396-402.
This cross-sectional survey of general surgery residents to assessed resident wellness and self-reported error and compared these results against National Surgical Quality Improvement Program (NSQIP) registry data to assess patient outcomes. Over a six-month period, 22.5% of residents self-reported a near-miss medical error and nearly 7% reported an error resulting in patient harm. Residents reporting harmful medical errors were more likely to report symptoms of burnout and poor psychiatric well-being, but researchers did not find any significant association between well-being and adverse postoperative patient outcomes reported in the NSQIP registry.
Hu Y-Y, Ellis RJ, Hewitt B, et al. New Engl J Med. 2019;381:1741-1752.
Physician burnout can negatively impact not only physician well-being, but patient safety as well. This national survey of general surgery residents found that about one-third of all respondents reported experiencing discrimination or abuse; 38.5% of residents reported weekly burnout systems and 4.5% reported suicidal thoughts within the past year. Residents reporting burnout or suicidal thoughts were more likely to have experienced discrimination, abuse or sexual harassment. Women reported more exposure to mistreatment, which may account for gender differences in rates of burnout and suicidal thoughts.
Woeltje KF, Olenski LK, Donatelli M, et al. Jt Comm J Qual Patient Saf. 2019;45:480-486.
… challenge health care organizations. This report describes a quality improvement intervention to reduce preventable harm in a 15-hospital health system using benchmarks, … in adverse events during the subsequent 5 years. A PSNet perspective discussed efforts to address preventable …
Ban KA, Gibbons MM, Ko CY, et al. Anesth Analg. 2019;128:879-889.
Standardization of care protocols has been shown to improve perioperative outcomes. This article presents the results of an evidence review to develop best practices for perioperative care around colorectal surgery. The authors acknowledge the need for local tailoring in implementing these recommendations.
Ban KA, Minei JP, Laronga C, et al. J Am Coll Surg. 2017;224:59-74.
Surgical site infections are a persistent and costly challenge to patient safety. These guidelines provide recommendations to reduce this common hospital-acquired condition, including policies for surgeon attire, hand hygiene, and equipment sterilization.
Sur MD, Schindler N, Singh P, et al. Am J Surg. 2016;211:437-44.
Surgical residents are often hesitant to speak up when they have concerns about decisions made by their supervisors. This study included semistructured interviews with 18 surgical residents, providing qualitative analyses of how they approach these situations.
Merkow RP, Ju MH, Chung JW, et al. JAMA. 2015;313:483-495.
… Surgical Quality Improvement Program . Nearly half a million operations were included, with an overall … important lessons for improvement, and he calls for a 50% reduction in surgical complication rates in the near …
Rajaram R, Chung JW, Jones AT, et al. JAMA. 2014;312:2374-84.
This observational study analyzed surgical outcomes before and after 2011 ACGME duty hours reform using data from the American College of Surgeons National Surgical Quality Improvement Program. Researchers applied difference-in-differences analysis, which can account for some of the uncertainty of nonrandomized data, a common concern in patient safety research. They assessed changes in surgical mortality and complication rates before and after implementation of duty hours restrictions in teaching hospitals. The authors compared this difference with mortality and complication rates during the same time period in nonteaching hospitals. Any variation between teaching and nonteaching sites could be attributed to the effects of duty hours, since the authors accounted for case mix and comorbidities. No differences in patient outcomes were observed, adding to the evidence that duty hours restrictions do not improve patient outcomes. Researchers also found no change in trainee examination scores, despite concerns that duty hours adversely impact trainee education. An editorial discussing this work and a companion study urge flexibility in duty hours for physicians in training.
Berner ES, Ray MN, Panjamapirom A, et al. J Gen Intern Med. 2014;29:1105-12.
… care visits. For the baseline stage, patients received a live follow-up call 3 weeks after their visit. In the … patients were contacted one week after their visit by a live call or an interactive voice response system call, respectively. There was a clear tradeoff—although fewer patients completed the …
Paruch JL, Ko CY, Bilimoria KY. JAMA Surg. 2014;149:887-8.
This commentary reveals limits to using the AHRQ Patient Safety Indicator for accidental puncture and laceration as a safety measure. The authors recommend solutions, such as using surgeon-reported data to determine appropriate variables and narrowing variables to include only injuries that require significant intervention.
… or time-outs are mandated by The Joint Commission as a strategy to prevent wrong-site surgery . This commentary … after surgery, evidence regarding their impact, and how a comprehensive unit-based safety program (CUSP) initiative designed and implemented a briefing and debriefing process. …