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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 - 12 of 12 Results
Thiels CA, Anderson SS, Ubl DS, et al. Ann Surg. 2017;266:564-573.
Opioid-related mortality is a patient safety concern. Prior studies have demonstrated that postdischarge opioid prescribing can lead to chronic use in opioid-naïve patients. This retrospective observational study examined the amount and duration of opioid prescribing following 25 common elective surgical procedures. Nearly all patients were prescribed opioids after elective surgery. The median amount of opioids prescribed, 375 oral morphine equivalents, was nearly twice the maximum recommended. Quantity of opioids prescribed differed by sex, body weight, age, and diagnosis, and there were also significant variations among the three institutions included in the study. The authors call for standardizing and optimizing postsurgical opioid prescribing.
Hyder JA, Hanson KT, Storlie CB, et al. Ann Surg. 2017;265:639-644.
Overlapping surgery refers to when two procedures are performed concurrently, but important portions occur at different times. Experts have raised concerns about the safety of scheduling coincident procedures. This study compared overlapping surgeries with nonoverlapping surgeries of the same type at a single referral center. After adjusting for surgeon and patient characteristics, investigators found no differences in inpatient mortality or length of stay. They performed an analogous analysis in the National Surgical Quality Improvement Program registry medical record data, which resulted in similar findings. Although these results should allay concerns about concurrent surgeries, the authors caution that further studies at multiple centers are needed to ensure that overlapping procedure practices do not carry excess risk to patients.
Wanta BT, Glasgow AE, Habermann EB, et al. Surg Infect (Larchmt). 2016;17:755-760.
Surgical site infections are an important type of health care–associated infection that safety efforts aim to prevent. This case-control study compared patients matched on age, gender, and elective procedure who developed surgical site infections with those who did not. Although investigators hypothesized that having additional personnel in the operating room would lead to higher likelihood of infection, after adjusting for patient- and procedure-related factors, they found this was not the case.
Thiels CA, Lal TM, Nienow JM, et al. Surgery. 2015;158:515-21.
Never events are devastating and preventable, and health care organizations are under increasing pressure to eliminate them completely. In this study, investigators evaluated all procedural never events using a validated human factors analysis method. They uncovered multiple underlying causes for each event. Cognitive failures were identified in about half the events. Preconditions, including environmental and technologic factors, were common contributors to events. Consistent with prior studies, the authors recommend enhancing communication among team members to augment safety. These results demonstrate the need to develop individual cognitive training interventions as well as systems approaches to address never events.
Etzioni DA, Wasif N, Dueck AC, et al. JAMA. 2015;313:505-11.
Similar to another study published in the same issue of the Journal of the American Medical Association, this retrospective study found no association between participation in the National Surgical Quality Improvement Program and surgical outcomes over time. This study examined 3 and a half years of data from the University HealthSystem Consortium, which represents a large cohort of academic medical centers.
WebM&M Case September 1, 2012
… for individual hospitals and surgical centers. … Robert R. Cima, MD, MA … Vice-chair, Quality and Safety, Department of …
Cima RR, Lackore KA, Nehring SA, et al. Surgery. 2011;150:943-9.
This study found that the Patient Safety Indicators lacked sensitivity and specificity for detecting postoperative adverse events, compared to the National Surgical Quality Improvement Program adverse event detection methodology.
Cima RR, Hale C, Kollengode A, et al. Arch Surg. 2010;145:641-6.
Wrong-site surgeries are a rare yet devastating complication for patients. Despite efforts to reduce the risk through adoption of Joint Commission’s Universal Protocol and implementation of briefings, these events continue to occur. This study explored a less understood risk for wrong-site surgery by focusing on the documentation transition from outpatient settings to the operating room. Investigators found a 1.4% error rate between the surgical listing and the performed procedure. While no wrong-site surgeries occurred, there were nearly 800 cases where this potential was noted and caught prior to surgery. The error rate was constant across specialties and most frequently associated with mistakes in laterality. After implementation of an electronic and standardized surgical listing form, the error rate was significantly reduced. Past AHRQ WebM&M commentaries have discussed the factors contributing to a near-miss wrong-site surgery and the role of time outs.
Regenbogen SE, Greenberg CC, Resch SC, et al. Surgery. 2009;145:527-35.
A cost-effectiveness analysis model was used to assess the utility of three methods for preventing retained surgical sponges: bar-coded sponges, radiofrequency ID–tagged sponges, and standard x-ray screening. The newer technologies were found to be more cost effective.
Cima RR, Kollengode A, Storsveen AS, et al. Jt Comm J Qual Saf. 2009;35:123-132.
This article describes a comprehensive strategy to reduce the incidence of retained foreign objects after surgical procedures. The authors highlight their institution's experience in planning, implementing, and evaluating the initiative.
Cima RR, Kollengode A, Garnatz J, et al. J Am Coll Surg. 2008;207:80-7.
Retained foreign objects (RFOs) are a rare but serious complication of surgical procedures. While radiofrequency detection systems, intraoperative radiographic screening, and bar coding have been described as strategies to prevent these occurrences, simple counting may not be as effective. This study examined more than 190,000 operations performed and found an actual RFO rate of 1 per 5,500 operations. Investigators discovered that the majority of RFOs occurred in patients with reportedly correct counts and even in patients who underwent intraoperative imaging. The authors advocate for new technologies that improve upon current imperfect systems to prevent RFOs. A case of an error of a retained sponge and a preventable death was discussed in an AHRQ WebM&M commentary.