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.
Boquet A, Cohen T, Diljohn F, et al. J Patient Saf. 2021;17:e534-e539.
This study classified flow disruptions affecting the anesthesia team during cardiothoracic surgeries. Disruptions were classified into one of six human factors categories: communication, coordination, equipment issues, interruptions, layout, and usability. Interruptions accounted for nearly 40% of disruptions (e.g., events related to alerts, distractions, searching activity, spilling/dropping, teaching moment).
Robinson SN, Neyens DM, Diller T. Am J Med Qual. 2017;32:285-291.
There is a recognized challenge in developing true opportunities for improvement with incident reporting. Using a case study method, this commentary describes a tested incident assessment framework that employs charting mechanisms to monitor both harm and nonharm events that result in process or workflow changes to indicate reliability of care in real time.
Diller T, Helmrich G, Dunning S, et al. Am J Med Qual. 2014;29:181-190.
Although root cause analysis is widely used to detect safety hazards, questions have been raised regarding its effectiveness. This study reports on one health system's experience using the Human Factors Analysis Classification System as an alternate method to investigate errors.