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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 22 Results
Prieto JM, Falcone B, Greenberg P, et al. J Surg Res. 2022;279:84-88.
Hospitalized children are vulnerable to patient safety risks. Using a large malpractice claims database, researchers found that a wide range of pediatric surgical specialties – including orthopedics, general surgery, and otolaryngology – are most frequently associated with malpractice lawsuits. The study identified several potentially modifiable factors (i.e., patient evaluations, technical performance, and communication) that can lead to improvements in pediatric surgical safety.
Morton CH, Hall MF, Shaefer SJM, et al. J Obstet Gynecol Neonatal Nurs. 2021;50:88-101.
Individuals involved in adverse maternal events require support both physically and emotionally. This guidance combines readiness, recognition, response, and reporting and systems-learning steps to aid birthing facility nurses and management in providing standardized help for mothers, families, and care team members that experience care-related harm.  
Gleason KT, Jones RM, Rhodes C, et al. J Patient Saf. 2021;17:e959-e963.
This study analyzed malpractice claims to characterize nursing involvement in diagnosis-related (n=139) and failure-to-monitor malpractice (n=647) claims. The most common contributing factors included inadequate communication among providers (55%), failure to respond (41%), and documentation failures (28%). Both diagnosis-related and physiologic monitoring cases listing communication failures among providers as a contributing factor were associated with a higher risk of death (odds ratio [OR]=3.01 and 2.21, respectively). Healthcare organizations need to take actions to enhance nurses’ knowledge and skills to be better engage them in the diagnostic process, such as competency training and assessment.
Liberman AL, Skillings J, Greenberg P, et al. Diagnosis (Berl). 2020;7:37-43.
Ischemic stroke, which often presents with non-specific symptoms and requires time-sensitive treatment, can be a source of diagnostic error and misdiagnosis. Using a large medical malpractice claims database, this study found that nearly half of all malpractice claims involving ischemic stroke included diagnostic errors, primarily originating in the ED. The analysis found that breakdowns in the initial patient-provider encounter (e.g., history and physical examination, symptom assessment, and ordering of diagnostic tests) contributed to most malpractice claims.
Mann S, Hollier LM, McKay K, et al. New Engl J Med. 2018;379:1689-1691.
Maternal morbidity has received increasing attention as a patient safety issue. This commentary recommends four strategies for improving obstetrics safety: focusing on prevention of complications, using multidisciplinary huddles to enhance communication, employing simulation as a teamwork training model, and developing partnerships between hospitals to ensure the best care is available.
Abrecht CR, Brovman EY, Greenberg P, et al. Anesth Analg. 2017;125:1761-1768.
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.
Quinn GR, Ranum D, Song E, et al. Jt Comm J Qual Patient Saf. 2017;43:508-516.
This analysis of closed malpractice claims sought to characterize the types of errors leading to malpractice claims in patients with cardiovascular disease. Diagnostic errors, especially in patients presenting with nonspecific symptoms but risk factors for cardiovascular disease, were a common cause of claims, implying that improving the accuracy of diagnosing cardiovascular disease may be a promising avenue for reducing morbidity.
Saedder EA, Brock B, Nielsen LP, et al. Eur J Clin Pharmacol. 2014;70:637-45.
This systematic review identified seven medication classes associated with the most severe medication errors: methotrexate, warfarin, nonsteroidal anti-inflammatory drugs, digoxin, opioids, aspirin, and beta-blockers. The authors suggest that focusing on these medication classes will reduce morbidity and mortality due to adverse drug events, a departure from the commonly advocated universal medication safety recommendations.
Kung A, Pratt SD. Int Anesthesiol Clin. 2014;52:86-110.
… clinics … Int Anesthesiol Clin … Labor and delivery (L&D) is a high-risk care environment where one error can lead … to further breakdowns . This commentary suggests that L&D units provide ideal opportunities to study multifaceted …
Salas E, Klein C, King HB, et al. Jt Comm J Qual Patient Saf. 2008;34:518-527.
This article provides an overview of debriefing as a learning tool in critical incident analysis and in clinical situations such as the operating room. Practical suggestions are provided to enable hospital leadership and team leaders to maximize the utility of debriefing sessions.
Nielsen PE, Goldman MB, Mann S, et al. Obstet Gynecol. 2007;62:294-295.
Crew resource management methods, initially developed in aviation, have been proposed as a means to reduce human errors in medicine through improved teamwork and communication. In this cluster-randomized trial, physicians and nurses on obstetrics wards underwent teamwork training based on the MedTeams model, which has been previously studied in the emergency department. The intervention did not result in improvement in patient (maternal or fetal) clinical outcomes or in the delivery of appropriate process measures. The authors ascribe this negative result to problems noted in other cluster-randomized trials of quality improvement interventions, such as inadequate time to implement the intervention, a relatively short follow-up period, and baseline variation between hospitals in the incidence of adverse events.
Perspective on Safety March 1, 2006
In recent years, the medical community has reached a near-consensus that team training and Crew Resource Management (CRM) techniques can improve patient safety. However, the most effective way to teach and implement these concepts is much less clear...
In recent years, the medical community has reached a near-consensus that team training and Crew Resource Management (CRM) techniques can improve patient safety. However, the most effective way to teach and implement these concepts is much less clear...
Sachs BP. JAMA. 2005;294:833-840.
Part of a series in JAMA entitled Clinical Crossroads, this case study discusses the unfortunate events surrounding a 38-year-old woman’s presentation to a labor and delivery unit. The case details a seemingly routine full-term pregnancy that rapidly evolved into a course of complications, ultimately leading to a fetal death, a hysterectomy, and a prolonged hospital course. The discussion shares the experience through the eyes of the patient, her husband, and the primary obstetrician. Further exploration of the case identified several specific factors and broader systems issues that contributed to the events. The author shares how this particular institution responded with overarching changes, including a greater emphasis on teamwork, communication, and appropriate staffing of labor and delivery units to promote safety.