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 - 20 of 34 Results

Perceptions of radiation safety culture in medical imaging by role.

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Moore QT, Haynes KW. Radiol Technol. 2023;94(5):337-347.

… Fostering a culture of safety is a core patient safety objective. This … organizational radiation safety culture. … Moore QT, Haynes KW. Radiol Technol . 2023;94(5):337-347. … Quentin … Kelli … Moore … Haynes … T. … Welch … Quentin T. Moore … Kelli Welch Haynes …

Family safety reporting in hospitalized children with medical complexity.

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Mercer AN, Mauskar S, Baird JD, et al. Pediatrics. 2022;150:e2021055098.

Children with serious medical conditions are vulnerable to medical errors. This prospective study examined safety reporting behaviors among parents of children with medical complexity and hospital staff caring for these patients in one tertiary children’s hospital. Findings indicate that parents frequently identify medical errors or quality issues, despite not being routinely advised on how to report safety concerns.

Surgical teams' attitudes about surgical safety and the surgical safety checklist at 10 years: a multinational survey.

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Urban D, Burian BK, Patel K, et al. Ann Surg. 2021;2:e075.

The WHO surgical safety checklist has been implemented in healthcare systems around the world. Survey responses from 2,032 surgical team members from high-income countries suggest that most respondents perceive the checklist as enhancing patient safety, but that not all team members are engaging with its use or feel confident in their role in the checklist process.

Supervision, interprofessional collaboration, and patient safety in intensive care units during the COVID-19 pandemic.

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Hennus MP, Young JQ, Hennessy M, et al. ATS Sch. 2021;2:397-414.

The surge of patients during the COVID-19 pandemic forced the redeployment of non-intensive care certified staff into intensive care units (ICU). This study surveyed both intensive care (IC)-certified and non-IC-certified healthcare providers who were working in ICUs at the beginning of the pandemic. Qualitative synthesis identified five themes related to supervision; quality and safety of care; collaboration, communication, and climate; recruitment, scheduling and team composition, and; organization and facilities. The authors provide recommendations for future deployments.

Situativity: A Family of Social Cognitive Theories for Clinical Reasoning and Error.

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Durning S, Holmboe E, Graber ML, eds. Diagnosis(Berl). 2020;7(3):151-344.

… C; van Merrienboer J; Schuwirth LWT … M. … A. … SJ … D. … E. … J. … ES … B. … KP … D. … J. … V. … M. … M. … R. … … … E. … G. … SM … A. … S. … A. … SJ … AR … LD … E. … JA … K. … H. … B. … AB … L. … K. … SR … CC … ZA … C. … P. … ML … … … Wallach … Altshuler … Hanley … Zabar … Gillespie … Haynes … Woodard … Croskerry … Graber … Docherty … Daniel … …

Implementing, Studying, and Reporting Health System Improvement in the Era of Electronic Health Records.

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Auerbach AD, Bates DW, Rao JK, et al, eds. Ann Intern Med. 2020;172(11_Supp):S69-S144.

Research and error reporting are important strategies to uncover problems in health system performance. This special issue highlights vendor transparency and context as important areas of focus to ensure electronic health records (EHR) research and reporting help improve system reliability. The articles cover topics such as a framework for research reporting, design of randomized controlled trials for technology studies, and designing research on patient portal enhancement.

Is WHO's surgical safety checklist being hyped?

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Urbach DR, Dimick JB, Haynes AB, et al. BMJ. 2019;366:l4700.

… BMJ (Clinical research ed.) … BMJ … Checklists are a popular yet controversial strategy for improving the safety … debate the weaknesses and strengths of checklists through a discussion of the evidence . …

Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist.

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Ramsay G, Haynes AB, Lipsitz SR, et al. Br J Surg. 2019;106:1005-1011.

Checklists have been shown to improve surgical safety in randomized controlled trials, but they have had varied impact when implemented in clinical practice. This interrupted time-series study examined surgical mortality before, during, and after implementation of the WHO surgical safety checklist. The rate of surgical mortality declined more during checklist introduction than it had before or after implementation, and hospital mortality did not decline among nonsurgical patients during the same time interval. The investigators, including checklist pioneer Atul Gawande, conclude that perioperative mortality has declined in association with checklist implementation. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

Scaling safety: the South Carolina Surgical Safety Checklist experience.

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Berry WR, Edmondson L, Gibbons LR, et al. Health Aff (Millwood). 2018;37:1779-1786.

This study in the Health Affairs patient safety theme issue examines the implementation of surgical safety checklists. Checklists have been shown to improve patient outcomes in randomized control trials, but implementation studies have not consistently demonstrated similar improvements. In this statewide initiative, implementation of the checklist varied significantly among sites. Factors associated with more successful implementation included greater leadership participation, frontline engagement, and more frequent activities for all involved groups, including surgeons, nurses, technicians, and administrators. Sites that invested more funding and time also saw greater checklist implementation. The authors conclude that hospitals that participated more did better. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

Patient Safety.

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Health Aff (Millwood). 2018;37(11):1723-1908.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.

Patterns of dementia treatment and frank prescribing errors in older adults with Parkinson disease.

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Mantri S, Fullard M, Gray SL, et al. JAMA Neurol. 2019;76:41-49.

This analysis of Medicare claims data found a significant prevalence of concurrent use of dementia medication with acetylcholinesterase inhibitors and anticholinergic medications. This medication combination is a frank medical error that the authors describe as a never event. Despite this, coprescription occurred in 44% of those prescribed dementia medication, and this medication error was more common in the southeastern and midwestern regions of the United States compared to the northeast or western regions.

Multisource evaluation of surgeon behavior is associated with malpractice claims.

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Lagoo J, Berry WR, Miller K, et al. Ann Surg. 2019;270:84-90.

… 360-degree reviews, in which team members evaluate a range of professional attributes and behaviors, were … informing others, and considering others' suggestions had a significantly higher risk for malpractice claims. Surgeons … behaviors among surgeons could mitigate malpractice risk. A previous WebM&M commentary discussed patient complaints as …

Miscommunication in the OR Leads to Anticoagulation Mishap

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WebM&M Case December 1, 2017

… The Case … A 63-year-old man with a history of coronary artery disease … catheters. … The Commentary … by Ian Solsky, MD, and Alex B. Haynes, MD, MPH … As highlighted by this case, communication …

Perception of safety of surgical practice among operating room personnel from survey data is associated with all-cause 30-day postoperative death rate in South Carolina.

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Molina G, Berry WR, Lipsitz S, et al. Ann Surg. 2017;266:658-666.

… Annals of surgery … Ann Surg … Establishing a robust culture of safety , in which all staff feel free to … culture. This study reports on the baseline results of a program that sought to improve surgical safety at hospitals … among operating room personnel in 31 hospitals using a validated instrument. The investigators found a relatively …

Predictors of in-hospital postoperative opioid overdose after major elective operations: a nationally representative cohort study.

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Cauley CE, Anderson G, Haynes AB, et al. Ann Surg. 2017;265:702-708.

… of surgery … Ann Surg … The large surge in opioid use is a serious patient safety problem. This retrospective study … opioid overdose increased over time. Patients with a substance abuse history were more likely to experience a postoperative opioid overdose, but hospital characteristics …

Mortality trends after a voluntary checklist-based surgical safety collaborative.

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Haynes AB, Edmondson L, Lipsitz S, et al. Ann Surg. 2017;266:923-929.

… clinical settings have been mixed. This study reports on a voluntary, statewide collaborative program to implement a surgical safety checklist in South Carolina hospitals. Participating sites undertook a multifaceted process to support checklist implementation …

Relationship between operating room teamwork, contextual factors, and safety checklist performance.

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Singer SJ, Molina G, Li Z, et al. J Am Coll Surg. 2016;223:568-580.e2.

Although checklists have been shown to improve safety and surgical mortality, they can be difficult to implement, which limits their effectiveness in clinical practice. This study examined whether perceptions of teamwork predicted checklist performance. Trained observers used standardized tools to rate the extent of checklist completion and quality of teamwork. They found that checklists were implemented as intended in only 3% of cases. Surgical teams with better surgeon buy-in to checklists, clinical leadership, communication, and overall teamwork completed more checklist components. Clinical factors, including older patient age and longer duration of surgery, were also associated with performing more of the checklist. The authors suggest that teamwork is critical to checklist implementation. A PSNet interview discussed the challenges of implementing checklists in health care.

Implementation of the surgical safety checklist in South Carolina hospitals is associated with improvement in perceived perioperative safety.

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Molina G, Jiang W, Edmondson L, et al. J Am Coll Surg. 2016;222:725-736.e5.

… substantiate calls for implementing checklists widely. A PSNet interview with Dr. Lucian Leape discussed his …

Sustainability and long-term effectiveness of the WHO surgical safety checklist combined with pulse oximetry in a resource-limited setting: two-year update from Moldova.

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Kim RY, Kwakye G, Kwok AC, et al. JAMA Surg. 2015;150:473-9.

… JAMA surgery … JAMA Surg … The World Health Organization's surgical safety checklist has been successfully implemented …

Patient Safety and Adherence to Self-Administered Medications

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WebM&M Case July 1, 2011

A man with HIV disease and a recent diagnosis of CNS toxoplasmosis presented to the ED for the third time in two weeks with headaches, seizures, and right-sided weakness. Physicians pursued a workup for treatment-resistant toxoplasmosis or another brain disease, but discovered that the patient had run out of his toxoplasmosis medications.

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