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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 25 Results
Soncrant C, Mills PD, Neily J, et al. J Patient Saf. 2020;16:41-46.
In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.
Hagley GW, Mills PD, Shiner B, et al. Phys Ther. 2018;98:223-230.
This analysis of the Veterans Health Administration root cause analysis database identified adverse events that occurred during rehabilitation services, such as physical therapy, occupational therapy, or speech and language therapy. Rehabilitation-related adverse events were extremely rare. The most common incidents were falls and delayed response to clinical deterioration.
Soncrant CM, Warner LJ, Neily J, et al. AORN J. 2018;108:386-397.
Root cause analysis has been widely promoted as a failure analysis tool for use in a variety of settings. This quality improvement project applied the method to patient falls in Veterans Health Administration operating rooms and developed recommendations to guide improvement. Areas of focus included team communication, restraint use, and staff education. An Annual Perspective provides insights regarding how to enhance root cause analysis to help investigate incidents and improve care.
Schwartz ME, Welsh DE, Paull DE, et al. J Healthc Risk Manag. 2018;38:17-37.
Communication failures are known to contribute to medical errors. In the field of aviation, crew resource management is used to teach teamwork and effective communication. In this study, researchers evaluated the impact of a team training program developed by the Veterans Health Administration National Center for Patient Safety and modeled after crew resource management training. The Teamwork and Safety Climate Questionnaire was used to evaluate safety climate prior to and after the training. They found that scores on the 27-item survey increased on all questions from baseline to 1 year and conclude that this type of team training improves patient safety by enhancing teamwork and ensuring effective communication among clinicians. A PSNet perspective provides insights on team training.
Neily J, Silla ES, Sum-Ping S (J) T, et al. Anesth Analg. 2017;126:471-477.
This study examined root cause analyses performed by the Veterans Health Administration to identify and characterize anesthesia-related safety events. Although a relatively small number of events were found, the authors identified several human factors solutions that, if implemented, could prevent common types of errors.
Riblet N, Shiner B, Watts B, et al. J Nerv Ment Dis. 2017;205:436-442.
This review of root cause analysis reports about suicide within 7 days of discharge from inpatient mental health facilities determined that most cases of suicide occurred prior to scheduled outpatient postdischarge follow-up. Many patients who went on to die by suicide left against medical advice but did not meet criteria to be held against their wishes, highlighting the conflict between safety and patient autonomy.
Miller K, Mims M, Paull DE, et al. JAMA Surg. 2014;149:774-9.
… This analysis of 14 cases of wrong-site thoracenteses, a procedure to remove fluid from around the lung, identified … the errors found that clinicians often failed to perform a time out and did not correctly document laterality in … death of a patient is discussed in a previous AHRQ WebM&M commentary . …
Lee A, Mills PD, Neily J, et al. Jt Comm J Qual Patient Saf. 2014;40:253-62.
This chart review study analyzed information from the Veterans Health Administration national database of root cause analyses to describe adverse events among veterans aged 65 years and older that resulted in sustained injury or death. Frequent incidents were falls, delays in diagnosis or treatment, and medication errors. Inadequate communication was the most common root cause identified in adverse events, and within this category, poor communication among providers (such as handoffs) often resulted in adverse events. Although virtually all root cause analyses led to implementation of action plans, only 40% were deemed effective. Compared to previous research, this study highlights robust use of root cause analysis while emphasizing the need for ongoing monitoring and improvement of corrective actions.