The PSNet Collection

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.

Leadership oversight for patient safety programs: an essential element.

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Moffatt-Bruce SD, Clark S, DiMaio M, et al. Ann Thorac Surg. 2017;105:351-356.

Leadership engagement in patient safety improvement efforts is an important component for success. This commentary highlights the role of clinical, administrative, and board leaders in creating an environment conducive to a culture of safety.

Investigating the causes of adverse events.

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Sanchez JA, Lobdell KW, Moffatt-Bruce SD, et al. Ann Thorac Surg. 2017;103:1693-1699.

Incident analysis enables learning from errors. This commentary explores elements of successful event investigation such as determining causal factors, describes root cause analysis, and reviews biases that can influence such investigations.

Patient safety: disclosure of medical errors and risk mitigation.

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Moffatt-Bruce SD, Ferdinand FD, Fann J. Ann Thorac Surg. 2016;102:358-62.

Although error disclosure is increasingly encouraged in health care, challenges to achieving transparency include liability and risk considerations, particularly for surgeons. This commentary describes the experiences of two health care systems that have implemented approaches to support transparent disclosure of medical errors.

Patient safety science in cardiothoracic surgery: an overview.

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Sanchez JA, Ferdinand FD, Fann J. Ann Thorac Surg. 2016;101:426-33.

The Society of Thoracic Surgeons National Database collects data to promote transparency and enhance technical expertise. Exploring safety sciences in cardiothoracic surgery, this commentary discusses how human error, accident causation, and high reliability can improve safety of care delivered by cardiac surgical teams.

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