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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 - 18 of 18 Results
Reinhart RM, Safari-Ferra P, Badh R, et al. Pediatrics. 2023;151:e2022056452.
Trigger tools are widely used for detecting potential adverse events among adult and pediatric inpatients. This article describes the development of a pediatric triggers program that can identify potential adverse events in near real-time to facilitate appropriate preventative measures. The tool includes criteria from the IHI Global Trigger Tool as well as novel triggers (such as pain reassessment time, hospital readmissions, and suspected sepsis). The trigger team created a process for linking triggers to the organizational incident reporting system based on specific criteria (to reduce false-positive reports). The trigger team is continuously developing and refining triggers based on stakeholder input.
Shah RK, Reinhart R, Cronin J. Otolaryngol Clin North Am. 2022;55:105-113.
Experts have advocated the importance of establishing the business case for safety. This article summarizes approaches to establishing the business case for safety through the use of telehealth case-based vignettes as examples. The authors discuss challenges for establishing a business case for safety and future directions.
Cramer JD, Balakrishnan K, Roy S, et al. OTO Open. 2020;4:2473974X2097573.
Various surgical specialties have implemented surgical checklists to improve patient safety outcomes. In this survey of 543 otolaryngologists, surgical safety checklists were widely used, but intraoperative adverse events continue to occur. The most common adverse events reported were medication errors, wrong site/patient/procedure events, and retained surgical items.
Parikh K, Hochberg E, Cheng JJ, et al. Pediatrics. 2020;145:e20191819.
This article explores one hospital’s use of facilitated apparent cause analysis  (ACA), which is defined as a limited investigation of a safety event resulting in limited or no harm and allows for fewer resources and a focus on preventative strategies. The article compares ACA versus root cause analysis and describes the process for completing facilitated ACA and the framework for an effective ACA, which includes (1) identifying the right event, (2) assembling the right team, (3) conducting the right analysis, and (4) focusing on the right action plan.
Roberson DW, Kirsh ER. Otolaryngol Clin North Am. 2019;52:1-9.
High-reliability organizations have developed methods for achieving safety despite hazardous conditions. This review summarizes the systems science, organizational structure, and interpersonal working methods that enable high-risk industries like health care to practice reliably and learn from mistakes.
McCormick ME, Stadler ME, Shah RK. Otolaryngol Head Neck Surg. 2015;152:778-782.
This commentary explores the unique challenges involved in integrating core principles of safety and quality improvement into otolaryngology–head and neck surgery education and describes strategies to address them. The authors draw from the experience of other specialty-focused medical education efforts to suggest topics to cover, effective ways to deliver content, and morbidity and mortality conferences as elements of successful programs.
Shah RK, Boss EF, Brereton J, et al. Otolaryngol Head Neck Surg. 2014;150:779-784.
This survey of otolaryngologists found very little overall progress in self-reported patient safety errors compared with a similar survey in 2004. For instance, wrong-site surgeries continue to occur despite garnering major attention over the past decade and being classified as a never event.
Shah RK, Nussenbaum B, Kienstra M, et al. Otolaryngol Head Neck Surg. 2010;143:37-41.
This survey of otolaryngologists found that many respondents had personal experience with wrong-site surgery. Incorrectly labeled or inverted radiographic images were frequently implicated as a contributing cause.
Rice-Townsend S, Hall M, Jenkins KJ, et al. J Pediatr Surg. 2010;45:1126-36.
This study sought to characterize the incidence and types of adverse events in pediatric surgery patients, using measures (the National Surgical Quality Improvement Program and the AHRQ Patient Safety Indicators) originally developed for identifying adverse events in adults. The authors argue that applying adult measures to a pediatric population overestimates the incidence of adverse events.
Shah RK, Roberson DW, Healy GB. Curr Opin Otolaryngol Head Neck Surg. 2006;14:164-9.
The authors assessed the literature specific to errors and adverse events in the practice of otolaryngology, summarize the findings, and suggest future actions to manage errors in their specialty.