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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 - 20 of 24 Results
Nosanov L, Elseth AJ, Maxwell J, et al. Am J Surg. 2023;226:726-728.
The second victim concept encompasses an important concern for the impact of unsafe care on health care workers. This commentary discusses the topic and the need for system-level solutions to ensure surgical team members involved with patient harm due to errors can heal, and in doing so, provide safe care to their patients.
Pratt BR, Dunford BB, Vogus TJ, et al. Health Care Manage Rev. 2022;48:14-22.
Organizational pressures sometimes lead to redeployment or task reallocation such as shifting infusion tasks from specialty nurse teams to generalist nurses. This survey of nurses in the United States found that infusion task reallocation led to increased job demands and reduced resources, thereby contributing to lower perceived organizational safety.
Bastakoti M, Muhailan M, Nassar A, et al. Diagnosis. 2022;9:107-114.
Misdiagnosis in the emergency department (ED) can result in increased morbidity and mortality. This retrospective chart review of patients admitted from the ED to hospital explored the concordance of ED admission and hospital discharge diagnoses. Results show 21.77% of patients had discordant diagnoses; discordant diagnosis was associated with increased length of stay, mortality, and up-triage to ICU.
Warm E, Ahmad Y, Kinnear B, et al. Acad Med. 2021;96:1268-1275.
Technical and procedural skills are an important emphasis of medical training. This article briefly summarizes the “as low as reasonably achievable” (ALARA) approach, which was developed for the nuclear industry and has been used in radiology. The authors outline how ALARA risk standards can be adapted by training program directors to measure procedural competency and assess and reduce bedside procedural risks.
Cohen AJ, Lui H, Zheng M, et al. JAMA Netw Open. 2021;4:e217058.
While rare, surgical never events can have tragic consequences for patients including permanent harm and death. This study analyzed 142 surgical never events reported to the California Department of Public Health. Retained foreign objects were the most commonly reported never event (66.2%), followed by wrong site or wrong patient (15.5%), and surgical burns (7.7%). Recommended strategies to reduce and prevent never events include proper use of intraoperative checklists.
DiSilvio B, Virani A, Patel S, et al. Crit Care Nurs Q. 2020;43:413-427.
This article discusses several aspects essential to surge planning and preparing for the COVID-19 pandemic, including surge planning, limiting health care worker exposure, logistics for medication delivery, delivering emergent care in patients with COVID-19, and safe practices for patient transport.
Czolgosz T, Cashen K, Farooqi A, et al. Pediatr Emerg Care. 2019;35:568-574.
Transitions of care happen multiple times in a patient’s hospital stay and are common times for preventable errors. This study evaluated the impact of errors in the emergency department management of pediatric patients who were admitted and then transferred to the pediatric ICU (PICU) within 12 hours of admission.  PICU transfers after an ED management error had significantly shorter floor length of stay, longer PICU stays, and received more interventions.

Hallbeck MS, Paquet V, eds. Appl Ergon. 2019;78:248-308.

Surgery requires specialized approaches to understand and prevent failure. This special issue features the work of multidisciplinary research teams that explored human factors and ergonomic concerns in the operating room that affect communication between robotic-assisted surgery teams, physical resilience of teams, instrument design and use, and poor implementation of briefings as improvement opportunities.
Stanisce L, Ahmad N, Deckard N, et al. Otolaryngol Head Neck Surg. 2019;160:1003-1008.
This pre–post study found that implementation of relative value unit–based payment in a head and neck surgery practice resulted in a higher volume of procedures. The incidence of adverse outcomes, including postoperative hospitalizations, infections, unplanned return surgeries, and emergency department visits, did not change. The authors conclude that the change in payment structure did not impact surgical safety.
Cheema E, Alhomoud FK, Kinsara ASA-D, et al. PLoS One. 2018;13:e0193510.
Pharmacists often perform medication reconciliation at hospital admission and discharge to prevent medication errors. This meta-analysis examined the efficacy of pharmacist-led medication reconciliation across 18 trials that included more than 6000 patients. Researchers found that pharmacist-led interventions reduced medication discrepancies but did not significantly affect adverse medication events or health care utilization. However, a recent large trial of pharmacist-led medication reconciliation with positive results was excluded from this meta-analysis.
Abbott TEF, Ahmad T, Phull MK, et al. Br J Anaesth. 2018;120:146-155.
… not uniformly demonstrated benefit. This study included a large, multicountry observational cohort of surgical outcomes before and after implementation of a checklist. Mortality declined after checklist … remained unchanged. Investigators also conducted a meta-analysis of surgical checklist studies (excluding …
Fisher K, Ahmad S, Jackson M, et al. Patient Educ Couns. 2016;99:1685-93.
This qualitative study used in-depth interviews with family members of critically ill patients to assess their perception of safety and quality problems. Nearly half of surrogate decision makers identified at least one safety concern, most often relating to communication from clinicians. Patient and family identification of errors is an important strategy for engaging patients in safety efforts.
Ahmed A, Ahmad M, Stewart M, et al. Laryngoscope. 2015;125:837-41.
This direct observation study revealed that surgeons performed with less dexterity and made more errors when distractions were present in the operating room compared to when no distraction occurred, and this effect was more pronounced in those with less experience. Consistent with prior work on interruptions and distractions, this finding underscores the need to augment health care work environments to improve safety.
Ahmed AH, Giri J, Kashyap R, et al. Am J Med Qual. 2015;30:23-30.
This systematic review found that patients who experience adverse events in intensive care units (ICUs) have significantly longer hospital and ICU stays. According to this study, the effect on mortality is less clear as the evidence linking adverse events to ICU deaths have been mixed and unreliable.
Amin MM, Graber ML, Ahmad K, et al. Acad Med. 2012;87:1428-33.
First-year residents who were allowed to nap for 20 minutes at midday had improved cognitive performance and fewer attentional failures than residents who did not nap. However, the study did not control for potential confounders, such as residents' caffeine intake.