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.
Tan J, Ross JM, Wright D, et al. Jt Comm J Qual Patient Saf. 2023;49:265-273.
Wrong-site surgery is considered a never event and can lead to serious patient harm. This analysis of closed medical malpractice claims on wrong-site surgery between 2013 and 2020 concluded that the risk of wrong-site surgery increases with spinal surgeries (e.g., spinal fusion, excision of intervertebral discs). The primary contributing factors to wrong-site surgery was failure to follow policy or protocols (such as failure to follow the Universal Protocol) and failure to review medical records.
Tan J, Krishnan S, Vacanti JC, et al. J Healthc Risk Manag. 2022;42:9-14.
… J Healthc Risk Manag … Inpatient falls are a common patient … design in perioperative areas to prevent falls. … Tan J, Krishnan S, Vacanti JC, et al. Patient falls in the … room setting: an analysis of reported safety events. J Healthc Risk Manag. Epub 2022 Apr 1. doi: 10.1002/jhrm.21503 …
Incident reporting systems are used to detect patient safety concerns and determine potential causes and opportunities for improvements. In the perioperative setting of one hospital, insufficient handoffs were the most common event type in the “coordination of care” category. Use of structured handoffs is recommended to improve communication and patient safety.
… J Patient Saf … Harm from opioids is a widely recognized … lower odds of discharge home, and higher odds of death. … Urman RD, Seger DL, Fiskio JM, et al. The burden of … on hospitalized previously opioid-free surgical patients. J Patient Saf. 2021;17(2):e76-e83. …
Young S, Shapiro FE, Urman RD. Curr Opin Anaesthesiol. 2018;31:707-712.
Office-based surgery is increasingly common, despite concerns regarding its safety. This review summarizes the literature on ambulatory surgery outcomes and identified risk factors such as case complexity, patient comorbidities, and anesthesia use. Few studies examined anesthesia use in dental care.
Mora JC, Kaye AD, Romankowski ML, et al. Adv Anesth. 2018;36:231-249.
Closed claim analysis can identify care problems and inform improvement strategies. This review examined closed claims for anesthesia and identified types of injuries experienced by patients receiving anesthesia. Situational awareness, distractions, equipment problems, and pain medicine complications contributed to anesthesia malpractice claims.
Stone AB, Urman RD, Kaye AD, et al. Curr Pain Headache Rep. 2018;22:46.
Recent efforts to address the opioid crisis include developing prescribing guidelines and changing policy. This review suggests that including a morphine milligram equivalent on opioid labels could reduce the potential for prescription-related harm. A PSNet perspective discussed opioid misuse as a patient safety problem.
Procedures are increasingly performed in the outpatient setting, but little is known about how elements of ambulatory surgery centers and office facilities impact patient experience and safety. This systematic review found no evidence to support a difference in the safety of procedures performed in office-based settings versus ambulatory surgery centers. The authors suggest that further research is needed to understand how specific facility characteristics such as accreditation may affect safety.
Opioid prescriptions for chronic, noncancer pain have contributed to the national opioid epidemic. Malpractice claims can identify trends in patient hazards and have been previously employed to better elucidate the opioid risks. This retrospective observational study examined all closed claims from a large malpractice carrier levied against pain medicine physicians. The resulting sample included 37 cases. Researchers found that improper medication management was the most common reason for a claim and only 27% resulted in payment. No claim filed when a provider terminated opioid therapy resulted in payment. Most of the patients who died in this study had cardiac, pulmonary, or psychiatric comorbidities. The authors recommend adhering to opioid prescribing guidelines, communicating opioid prescribing risks to patients, documenting those conversations, and monitoring for diversion as strategies to reduce malpractice claims. An Annual Perspective summarized opioid-related patient safety research.
Although prior research has demonstrated that safety culture can vary widely between different clinical areas in the same hospital, less is known about how safety culture varies in perioperative areas. Researchers administered the AHRQ Hospital Survey on Patient Safety Culture at a single hospital in 2014. They found that among the 431 respondents working in the perioperative setting, there was significant variability in safety culture by provider type, years in training, and dimension of safety climate.
Karamnov S, Sarkisian N, Grammer R, et al. J Patient Saf. 2014;13:111-121.
… Journal of Patient Safety … J Patient Saf … The recent death of comedienne Joan Rivers , … sedation-related complications. A previous AHRQ WebM&M perspective described office-based anesthesia as the "Wild …
… of the American Society for Healthcare Risk Management … J Healthc Risk Manag … Checklists are an important patient … their effectiveness in this area. A past AHRQ WebM&M commentary discussed a serious error that occurred after a …