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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
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.
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.
Kronman MP, Hall M, Slonim A, et al. Pediatrics. 2008;121:e1653-e1659.
The Agency for Healthcare Research and Quality's Patient Safety Indicators (PSIs) have been widely used to identify patient safety events in adult populations. Pediatric-specific PSIs have recently been developed as well. This study used PSI data from more than 400,000 pediatric hospital admissions to estimate the impact on costs and hospital length of stay associated with inpatient adverse events. These data provide the first estimate of the economic impact of preventable adverse events in children's hospitals. Based on similar research in adults, the Centers for Medicare and Medicaid Services recently decided to stop reimbursing hospitals for costs associated with certain 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.
Tham E, Calmes HM, Poppy A, et al. Pediatrics. 2011;128:e438-45.
Pediatric inpatients are at high risk for adverse drug events (ADEs). Pediatric-specific trigger tools and computerized surveillance systems are effective methods to detect ADEs and identify opportunities for prevention. This performance-improvement collaborative implemented a multifaceted change strategy in 13 institutions and produced a 42% reduction in ADEs. The change strategies included efforts to reduce interruptions during medication administration, adopt consensus-based protocols and order sets, ensure high reliability with the Five Rights, and foster a culture of safety. The interventions had the greatest impact on opioid-related ADEs, which decreased by 51% across participating hospitals. The authors recommend using quality improvement collaboratives to drive improved patient care.