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 596 Results

Use of technology to improve the adherence to surgical safety checklists in the operating room.

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Pati AB, Mishra TS, Chappity P, et al. Jt Comm J Qual Patient Saf. 2023;Epub Apr 22.

The World Health Organization (WHO) Surgical Safety Checklist is widely used, but implementation challenges remain. This article describes the development of an electronic version of the surgical safety checklist adapted for use on a personal device, and compared its use against the traditional paper-based checklist. The electronic checklist had 100% use (compared to 98% for the traditional checklist) and significantly higher frequency of completion (100% vs. 27%).

Proactive patient safety: focusing on what goes right in the perioperative environment.

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Duffy C, Menon N, Horak D, et al. J Patient Saf. 2023;19:281-286.

Resiliency and proactive safety behaviors can improve safety in the perioperative environment. In this article, the authors describe safety attitudes of perioperative staff after participating in a proactive activity, One Safe Act (OSA). Most participants reported the OSA activity would change their work practices, improve their work unit's ability to deliver safe care, and demonstrate their colleagues' commitment to patient safety.

APSF Stoelting Conference.

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Anesthesia Patient Safety Foundation. September 6–7, 2023; Red Rock Casino Resort and Spa, Las Vegas, NV.

Anesthesia is a high-risk activity that has achieved safety successes. This hybrid conference will explore topics related to the theme of “Emerging Medical Technologies – A Patient Safety Perspective on Wearables, Big Data and Remote Care.”

In situ simulation-based team training and its significance for transfer of learning to clinical practice--a qualitative focus group interview study of anaesthesia personnel.

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Finstad AS, Aase I, Bjørshol CA, et al. BMC Med Educ. 2023;23:208.

Non-technical skills (NTS), such as teamwork, can be learned through simulation-based team training (SBTT) but must also transfer into practice to be successful. This study reports on an anesthesia team’s transfer of NTS into clinical practice through focus groups at two weeks and six months after participation in in-situ interprofessional SBTT. Participants reported improved practice, but requested more frequent SBTT and debriefing, both in practice and after trainings.

Crisis scenarios for simulation-based nontechnical skills training for cardiac surgery teams: a national survey among cardiac anesthesiologists, cardiac surgeons, clinical perfusionists, and cardiac operating room nurses.

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Kemper T, van Haperen M, Eberl S, et al. Simul Healthc. 2023;Epub Mar 6.

Simulation-based training provides a safe environment to learn technical and nontechnical skills (NTS) such as communication and teamwork. This article describes the development of nontechnical, simulation-based crisis scenarios in cardiothoracic surgery. Cardiac surgeons, cardiac anesthesiologists, cardiac perfusionists, and cardiac operating room nurses from all surgical cardiac centers in the Netherlands participated in the development of 13 crisis scenarios. The list of selected and non-selected scenarios and an example scenario design template are provided.

Distractions in the operating room: a survey of the healthcare team.

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Nasri B-N, Mitchell JD, Jackson C, et al. Surg Endosc. 2023;37:2316-2325.

Distractions in the operating room can contribute to errors. Based on survey responses from 160 healthcare workers, this study examined perceived distractions in the operating room. All participants ranked auditory distractions as the most distracting and visual distractions as the least distracting, but the top five distractors fell into the equipment and environmental categories – (excessive heat/cold, team member unavailability, poor ergonomics, equipment unavailability, and competitive demand for equipment). Phone calls/pagers/beepers were also cited as a common distractor.

An evidence synthesis on perioperative handoffs: a call for balanced sociotechnical solutions.

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Abraham J, Duffy C, Kandasamy M, et al. Int J Med Inform. 2023;174:105038.

Multiple handoffs occur during the perioperative period, each presenting an opportunity for miscommunication and patient harm. This review uses the Systems Engineering Initiative for Patient Safety (SEIPS) framework to describe the barriers and enablers for improving staff communication pre-, intra-, and post-operative handoffs. Structured hand-offs, checklists, protocols, and interprofessional teamwork were cited as enablers for improved communication.

Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.

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WebM&M Case March 29, 2023

A 48-year-old obese man with a history of obstructive sleep apnea was placed under general anesthesia for corneal surgery. On completion of the operation, the patient was transferred to a motorized gurney to extubate him in a sitting position because the operating room (OR) table was too narrow. However, while the team was moving him from the OR table to the gurney, a nurse inadvertently pulled on the anesthetic machine hoses. The endotracheal tube became dislodged and the patient could not be ventilated.

Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame.

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Brattebø G, Flaatten HK. Curr Opin Anaesthesiol. 2023;36:240-245.

Latent errors or conditions are subtle and can be difficult to identify before an incident occurs. This commentary calls for moving from the reactive "bad apple" paradigm to a proactive just culture, where errors and near misses serve as organizational learning opportunities, and not as a time for individual discipline.

Healthcare professionals' perception of safety culture and the Operating Room (OR) Black Box technology before clinical implementation: a cross-sectional survey.

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Strandbygaard J, Dose N, Moeller KE, et al. BMJ Open Qual. 2022;11:e001819.

Operating room (OR) “black boxes”;– which combine continuous monitoring of intraoperative data with video and audio recording of operative procedures – are increasingly used to improve clinical and team performance. This study surveyed OR professionals in Denmark and Canada about safety attitudes and privacy concerns regarding OR black box use. Participants were primarily concerned with safety climate and teamwork in the OR and use of OR black boxes can support learning and improvements in these areas. The North American cohort expressed more concerns about data safety.

Closed-loop communication in interprofessional emergency teams: a cross-sectional observation study on the use of closed-loop communication among anesthesia personnel.

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Gjøvikli K, Valeberg BT. J Patient Saf. 2023;19:93-98.

Closed-loop communication prevents confusion and ensures the healthcare team is operating under a shared mental model. In order to investigate closed-loop communication in real-life care (as opposed to simulations), researchers observed 60 interprofessional teams, including 120 anesthesia personnel. The number of callouts, check-backs, and confirmations were analyzed, revealing only 45% of callouts resulted in closed-loop communication.

Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.

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WebM&M Case March 15, 2023

A 48-year-old woman was placed under general anesthesia with a laryngeal mask. The anesthesiologist was distracted briefly to sign for opioid drugs in a register, and during this time, the end-tidal carbon dioxide alarm sounded. Attempts to manually ventilate the patient were unsuccessful. The anesthesiologist asked for suxamethonium (succinylcholine) but the drug refrigerator was broken and the medication had to be retrieved from another room.

Surgical fire in the United States: 2000-2020.

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Grauer JS, Kana LA, Alzouhayli SJ, et al. Surgery. 2022;173:357-364.

Surgical fires, while rare, can result in the injury, permanent disability, or death of patients or healthcare workers. Between 2000 and 2020, 565 surgical fires resulting in injury were reported to the FDA’s Manufacturer and User Facility Device Experience (MAUDE) database. Fires were most likely to occur during upper aerodigestive tract and head and neck surgeries; these were also most likely to result in life-threatening injury.

Evaluation of policies limiting opioid exposure on opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large American health system.

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Rennert L, Howard KA, Walker KB, et al. J Patient Saf. 2023;19:71-78.

High-risk opioid prescribing can increase the risk of abuse and overdose. This study evaluated the impact of four opioid prescribing policies for opioid-naïve patients – nonopioid medications during surgery, decreased opioid doses in operating rooms, standardized electronic health record alerts, and limits on postoperative opioid supply – implemented by one opioid stewardship program in a large US healthcare system between 2016 and 2018. Post-implementation, researchers observed decreases in postoperative opioid prescription doses, fewer opioid prescription refills, and less patient-reported discharge pain.

Compliance with and barriers to implementing the surgical safety checklist: a mixed-methods study.

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Aydin Akbuga G, Sürme Y, Esenkaya D. AORN J. 2023;117:e1-e10.

The World Health Organization’s Surgical Safety Checklist has been used in populations around the globe to reduce surgical complications and improve operating room teamwork. This mixed methods study involved nearly 150 surgical nurses in Turkey. Nurses reported inconsistent use of the checklist, described barriers to its use, and offered suggestions to increase compliance with completion.

Association between opioid tapering and subsequent health care use, medication adherence, and chronic condition control.

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Magnan EM, Tancredi DJ, Xing G, et al. JAMA Netw Open. 2023;6:e2255101.

Rates of prescription opioid misuse and abuse led to recommendations for dose tapering for patients with chronic pain. However, concerns have been raised about the potential harms associated with rapidly decreasing doses or discontinuing opioids. Building on previous research, these researchers used a large claims database to explore the unintended negative consequences of tapering patients on stable, long-term opioid therapy. Findings indicate that opioid tapering was associated with fewer primary care visits, greater numbers of emergency department visits, and reduced adherence to antihypertensive and antidiabetic medications.

Cognitive biases in surgery: systematic review.

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Armstrong BA, Dutescu IA, Tung A, et al. Br J Surg. 2023;110:645-654.

Cognitive biases are a known source of misdiagnosis and post-operative complications. This review sought to identify the impact of cognitive biases on surgical performance and patient outcomes. Through thematic analysis of 39 studies, the authors identified 31 types of cognitive bias across six themes. Importantly, none of the included studies investigated the source of cognitive bias or mitigation strategies.

Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists.

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Kelly FE, Frerk C, Bailey CR, et al. Anaesthesia. 2023;78:458-478.

Human factors engineering has the potential to mitigate failures by designing workspaces and processes to prevent errors from occurring. This guidance uses the hierarchy of controls framework to organize human-factors recommendations focusing on the design of anesthesia environments and equipment to infuse protections into care service.

Artificial intelligence, patient safety, and achieving the quintuple aim in anesthesiology.

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Tan JM, Cannesson MP. APSF Newsletter. 2023;38(2):1,3–4,7.

Technological advancement is a hallmark of anesthesiology safety improvement. This article discusses the opportunities that artificial intelligence (AI) represents for anesthesiologists and provides a practical framework for understanding the important relationship to be optimized between AI and perioperative care to support patient safety.

Intended and unintended consequences: changes in opioid prescribing practices for postsurgical, acute, and chronic pain indications following two policies in North Carolina, 2012-2018 - controlled and single-series interrupted time series analyses.

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Maierhofer CN, Ranapurwala SI, DiPrete BL, et al. Drug Alcohol Depend. 2023;242:109727.

A national focus on reducing opioid misuse and abuse has resulted in changes to opioid prescribing policies and practice. This retrospective longitudinal study explored changes in prescribing rates, supply and dose of opioid prescriptions after changes in opioid prescribing policies in North Carolina. Researchers found that that prescribing patterns for acute and postsurgical pain patients (but not chronic pain patients) decreased after a state medical board initiative to reduce high-dose and high-volume. Further, new legislation to limit initial opioid prescriptions for acute and postsurgical pain led to a decrease in prescribing for cancer patients with chronic pain, but did not lead to reductions among patients with acute, postsurgical, or non-cancer chronic pain.

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