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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
Schulz CM, Burden A, Posner KL, et al. Anesthesiology. 2017;127:326-337.
Failure to maintain situational awareness can adversely impact patient safety. In this closed claims analysis of anesthesia malpractice claims for death or brain damage, researchers found that situational awareness errors on the part of the anesthesiologist contributed to death or brain damage in 74% of claims.
WebM&M Case April 1, 2015
During laparoscopic subtotal colon resection for adenocarcinoma, a patient's bladder was accidentally lacerated and surgeons repaired it without difficulty. As nurses set up bladder irrigation equipment, no one noticed the bag of solution was dripping into the power supply of an anesthesiology monitor. Suddenly sparks and flames began shooting from the monitor, and the OR filled with black smoke. Fortunately, the fire was extinguished quickly and neither the patient nor any OR staff was injured.
Davies JM, Posner KL, Lee LA, et al. Anesthesiology. 2009;110:131-139.
The use of closed claims data to identify risk exposures, highlight safety issues, and drive improvement changes have been applied in ambulatory care, surgery, emergency medicine, and obstetrics. This study uses a previously described database to compare liability profiles in obstetric anesthesia before and after 1990. Investigators found that while the proportion of maternal death and newborn death or brain damage claims decreased in recent years (though still a leading cause), maternal nerve injury and back pain increased in later claims. Delays in anesthesia care, substandard care, and poor communication between the obstetrician and anesthesiologist are identified as preventable causes of newborn injury.
Khuri SF, Henderson WG, Daley J, et al. Ann Surg. 2008;248:329-36.
The Patient Safety in Surgery study documented remarkable improvements in postoperative outcomes at Veterans Affairs hospitals following implementation of a quality improvement program. This study demonstrated similar improvement in clinical outcomes, including surgical site infection rates, following implementation of the program in private sector hospitals.
Bhananker SM, Posner KL, Cheney FW, et al. Anesthesiology. 2006;104:228-234.
Using closed malpractice claims from a previously described database, this study discovered significant patient injury associated with monitored anesthesia care (MAC) and a liability profile similar to that of general anesthesia. Investigators performed a detailed analysis of more than 120 MAC claims, compared them with those of general and regional anesthesia, and report on the claim characteristics. MAC claims involved older and more ill patients, with respiratory depression being the most frequent occurrence leading to patient injuries. The authors conclude that more than half of the claims would be preventable with improved monitoring strategies.