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.
This systematic review of opioid stewardship practices following surgery identified eight intervention studies intended to reduce postsurgical opioid use. Organizational-level interventions such as changing orders in the electronic health record, demonstrated clear reductions in opioid prescribing. Clinician-facing interventions such as development and dissemination of local guidelines also led to reduced opioid prescribing. The authors emphasize the need for more high-quality evidence on opioid stewardship interventions.
Ban KA, Gibbons MM, Ko CY, et al. Anesth Analg. 2019;128:879-889.
Standardization of care protocols has been shown to improve perioperative outcomes. This article presents the results of an evidence review to develop best practices for perioperative care around colorectal surgery. The authors acknowledge the need for local tailoring in implementing these recommendations.
Mathews SC, Demski R, Hooper JE, et al. Acad Med. 2017;92:608-613.
Program infrastructure that incorporates the knowledge of staff at executive and unit levels can enable system improvements to be sustained over time. This commentary describes how an academic medical center integrated departmental needs with overarching organizational concerns to inform safety and quality improvement work. The authors highlight the need for flexibility and structure to ensure success.
… yearly. More recent studies have challenged that estimate. A recent British study found that only 3.6% of inpatient … lack of accurate strategies for measuring safety events—a problem also highlighted in a recent commentary by two … too many patients die needlessly due to unsafe care. … Makary MA, Daniel M. Medical error-the third leading cause of …
Xu T, Wick EC, Makary MA. BMJ Qual Saf. 2016;25:311-314.
This commentary explores elements of the hospital environment that can contribute to sleep deprivation and malnutrition in patients, including care complexity, hospital census, poor communication, and noise. The authors advocate for designing more patient-centered hospital systems to prevent this type of harm.
Gould LJ, Wachter PA, Aboumatar HJ, et al. Jt Comm J Qual Patient Saf. 2015;41:387-395.
… describes the development of 14 clinical communities as a way to support institutional quality improvement goals in a large health care system. The authors report the benefits … collective knowledge. The article highlights the use of a unit-level engagement model and physician champions as key …
Lyu HG, Cooper M, Mayer-Blackwell B, et al. J Patient Saf. 2017;13:199-201.
… of patient safety … J Patient Saf … Patient stories are a growing component of understanding the impact of medical … related to medical care. Almost half of respondents filed a complaint with an oversight agency, a much higher proportion than indicated in previous studies . …
… Catastrophic payments most frequently arose as a result of a diagnostic error and were more likely to occur for … malpractice system was discussed by Dr. Troyen Brennan in a past AHRQ WebM&M interview . …
Operating room briefings or time-outs are mandated by The Joint Commission as a strategy to prevent wrong-site surgery. This commentary explores the use of briefings both before and after surgery, evidence regarding their impact, and how a comprehensive unit-based safety program (CUSP) initiative designed and implemented a briefing and debriefing process.
Tehrani ASS, Lee HW, Mathews SC, et al. BMJ Qual Saf. 2013;22:672-680.
… clear from this study that diagnostic errors account for a large proportion of preventable patient harm. Recent … level and at the system level . The human costs of a fatal diagnostic error—for the patient and the clinician—were vividly illustrated in a recent graphic-novel style article . …
Mehtsun WT, Ibrahim AM, Diener-West M, et al. Surgery. 2013;153:465-472.
More than a decade ago, stories of wrong site surgeries and retained surgical objects galvanized the patient safety movement. Despite public uproar and attention focused on these never events, such incidents continue to occur at alarming rates. This study found that surgeons make these mistakes more than 4000 times per year in the United States. Related malpractice payments have amounted to more than $1.3 billion over the last 20 years. Although this financial burden is substantial, it may pale in comparison to the degree of patient harm resulting from these preventable errors. An incident of wrong-site surgery is discussed in an AHRQ WebM&M commentary.
Brooke BS, Dominici F, Pronovost P, et al. Surgery. 2012;151:651-9.
Mortality after inpatient surgery varies widely between hospitals, with much of this variation thought to be due to differences in how well hospitals treat specific postoperative complications. This study of nearly 80,000 Medicare patients sought to determine whether implementation of the National Quality Forum's (NQF) Safe Practices for Better Healthcare was associated with more effective treatment of postoperative complications. The authors found that hospitals that had fully implemented the safe practices had a lower incidence of failure to rescue and lower overall postoperative mortality. Although a prior study found that adoption of the NQF recommendations was not associated with improved mortality, that study was not able to distinguish between full or partial implementation of the NQF safe practices, as was done in this study.