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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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Fabri PJ, Zayas-Castro JL. Surgery. 2008;144:557-63; discussion 563-5.
Individual and system factors have been implicated in past analyses of surgical errors. This prospective study developed an error classification system and applied it to more than 9800 surgical procedures examined. Investigators discovered major complications in 3.4% of cases, with surgical technique, judgment errors, inattention to detail, and incomplete understanding as the most common contributing factors. System and communication errors were infrequently identified, a notable finding given past research suggesting their importance in surgical safety. The authors highlight that their findings challenge "popular wisdom" about the role of systems in patient safety and advocate for greater attention to human factor causes of error.