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.
Dorken Gallastegi A, Mikdad S, Kapoen C, et al. J Surg Res. 2022;274:185-195.
While interoperative deaths (IODs) are rare, they are catastrophic events. This study analyzed five years of data on IODs from a large academic medical center. The authors describe three phenotypes: patients with traumatic injury, those undergoing non-trauma-related emergency surgery, and patients who die during an elective procedure from medical cardiac arrests or vascular injuries. This classification framework can serve as a foundation for future research or quality improvement processes.
El Hechi MW, Bohnen JD, Westfal M, et al. J Am Coll Surg. 2019;230:926-933.
This paper describes the implementation of a "second victim" peer-support program in the surgery department at a tertiary care center. The program trained surgical attendings and trainees to provide peer-support for other surgeons involved in major adverse events. After one-year follow-up, 81% of affected surgeons elected to receive peer support. The majority (81%) felt the program had a positive impact on safety culture by providing a confidential, safe, and timely intervention for so-called "second victims". A 2011 Perspective on Safety with Dr. Albert Wu discussed ways that organizations can support "second victims."
Bohnen JD, Mavros MN, Ramly EP, et al. Ann Surg. 2017;265:1119-1125.
Intraoperative adverse events have been shown to increase the risk of hospital readmission. In this study, investigators found that intraoperative adverse events during abdominal surgery were associated with increased postoperative mortality, morbidity, and length of stay.
Rosen AK, Itani KMF, Cevasco M, et al. Med Care. 2011;50.
The Patient Safety Indicators (PSIs) had only moderate predictive accuracy for identifying adverse events compared with independent clinical review. As shown in prior research, many errors identified by the PSIs were actually present on admission.
Kaafarani HMA, Borzecki AM, Itani KMF, et al. J Am Coll Surg. 2010;212:924-934.
This study examined the predictive value of three AHRQ Patient Safety Indicators intended to detect postoperative adverse events and found that these indicators were not accurate enough to be used as quality measures.