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.
Hospitals that implement quality improvement initiatives improve patient safety but also incur financial expenses related to implementation, sustainment, and reporting. This study used data from the American Hospital Association and Hospital Compare to evaluate the relationship of financial performance and quality in hospitals performing cardiac surgery. The findings indicate hospitals with lower Patient Safety Indicator 90 (PSI 90) scores had poorer financial performance in the following year.
Rose J, Evans C, Barleben A, et al. JAMA Surg. 2014;149:926-32.
Using AHRQ Patient Safety Indicators to compare two surgical techniques for abdominal aortic aneurysm repair, this chart review study found that endovascular repair was safer, emphasizing the utility of these measures for characterizing surgical safety despite controversy about their accuracy.
The increasing technological sophistication of hospital care has led to greater appreciation of the potential safety hazards posed by medical devices. This observational study used the AHRQ Patient Safety Indicators to examine whether the introduction of a new medical device, the da Vinci robot, led to a change in surgical processes or surgeon performance for a specific procedure, radical prostatectomy. The authors found that during initial adoption of the new technique and device, there was an increased risk of unsafe practice compared with the standard method of conducting radical prostatectomy. This finding emphasizes the need to create safety processes and monitoring when novel devices and procedures are introduced, given that voluntary reporting underestimates safety problems related to devices. A recent AHRQ WebM&M perspective discusses the challenges associated with ensuring medical device safety in the complex health care environment.
Camp M, Chang DC, Zhang Y, et al. Arch Surg. 2010;145:1085-90.
Retained surgical instruments are among the most dramatic of medical errors, and are considered never events. Although these errors are rare, prior studies in adults have defined risk factors for retained instruments, which include emergency surgeries and intraoperative changes in the surgical plan. This study examined the problem of retained foreign bodies in pediatric surgery, using cases identified by the AHRQ Pediatric Quality Indicators. Gynecologic surgeries emerged as the only type of surgery significantly associated with an increased risk of retained instruments, and retained foreign bodies were associated with increased hospital length of stay and costs (but not increased mortality). Despite the persistence of this problem, controversy remains around how to prevent such errors.
Chang DC, Handly N, Abdullah F, et al. Ann Surg. 2008;247:327-34.
Using AHRQ's Patient Safety Indicators, this study discovered that events expected to be random in nature in fact occur with greater likelihood in trauma patients who are male, black, and older than 35 years.