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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 - 16 of 16 Results
Enumah SJ, Sundt TM, Chang DC. J Healthc Manag. 2022;67:367-379.
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.
Enumah SJ, Resnick AS, Chang DC. PLOS ONE. 2022;17:e0266696.
While quality and patient safety initiatives are implemented to improve patient outcomes, they also typically include a financial cost which must be balanced with expected outcomes. This study compared hospitals’ financial performance (i.e., financial margin and risk of financial distress) and outcomes (i.e., 30-day readmission rates, patient safety indicator-90 (PSI-90)) using data from the American Hospital Association and Hospital Compare. Hospitals in the best quintiles of readmission rates and PSI-90 scores had higher operating margins compared to the lowest rated hospitals.
Bloom JP, Moonsamy P, Gartland RM, et al. J Thorac Cardiovasc Surg. 2019.
This study examined whether increased team turnover raises the likelihood of sharp count errors by surgical teams and negatively affects patient outcomes. Analyses of all cardiac operations performed at Massachusetts General Hospital over a 5-year period revealed that sharp count errors were associated with higher rates of in-hospital mortality and were more prevalent with increased team turnover and on weekends. A prior Web M&M commentary discusses adverse outcomes arising due a retained foreign object during cardiac surgery.
Axtell AL, Moonsamy P, Melnitchouk S, et al. J Thorac Cardiovasc Surg. 2019.
Physician work hours and fatigue can impact patient safety, particularly among subspecialties focused on high-risk patients. This retrospective cohort study examined outcomes of patients undergoing nonemergent cardiac surgery occurring before or after 3pm. The investigators found no differences in mortality, complications, or length of stay and posit that this may stem from resource availability in these specialized care settings regardless of the time of day.
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.
Parsons K, Messer K, Palazzi K, et al. JAMA Surg. 2014;149:845-51.
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.
Wahr JA, Prager RL, Abernathy JH, et al. Circulation. 2013;128:1139-1169.
This scientific statement from the American Heart Association (AHA) reviews the current state of knowledge on safety issues in the operating room (OR) and provides detailed recommendations for hospitals to implement to improve safety and patient outcomes. These recommendations include using checklists and formal handoff protocols for every procedure, teamwork training and other approaches to enhance safety culture, applying human factors engineering principles to optimize OR design and minimize fatigue, and taking steps to discourage disruptive behavior by clinicians. AHA scientific statements, which are considered the standard of care for cardiac patients, have traditionally focused on clinical issues, but this article (and an earlier statement on medication error prevention) illustrates the critical importance of ensuring safety in this complex group of patients.
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.