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Patient Safety Network

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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    • Retained foreign bodies: risk and outcomes at the national level.
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    • Al-Qurayshi ZH, Hauch AT, Slakey DP, et al. J Am Coll Surg. 2015;220:749-59.
    Leaving a surgical item behind after a procedure is a never event. This retrospective cross-sectional study sought to identify risk factors and outcomes of retained foreign bodies. Nearly one-third of incidents involving retained foreign objects were reported after gastrointestinal procedures. Risk of retained surgical items was highest in teaching hospitals.
    Using simulation to improve root cause analysis of adverse surgical outcomes.
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    • Slakey DP, Simms ER, Rennie K, et al. Int J Qual Health Care. 2014;26:144-50.
    Comparing the use of case simulation with root cause analysis for investigating adverse surgical outcomes, this study found that simulating the event identified more system errors and focused less on individual errors. This result supports wider implementation of simulation for evaluating adverse events.
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