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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 573 Results

DePeau-Wilson M. MedPage Today. January 13, 2023.

The use of anesthesia in ambulatory settings presents both advantage and risk to patients and clinicians. This article discusses evidence defining these issues. It suggests that improved collaboration with anesthesiologists represents opportunities for nonoperating room anesthesia safety.
Greig PR, Zolger D, Onwochei DN, et al. Anaesthesia. 2022;Epub Dec 14.
Cognitive aids, such as checklists and decision aids, can reduce omissions in care and improve patient safety. This systematic review including 13 randomized trials found that cognitive aids in clinical emergencies reduced the incidence of missed care steps (from 43% to 11%) and medical errors, and improved teamwork, non-technical, and conflict resolution scores.
Barrett AK, Sandbrink F, Mardian A, et al. J Gen Intern Med. 2022;37:4037-4046.
Opioid medication use is associated with an increased risk of adverse events; however research has shown sudden discontinuation of opioids is also associated with adverse events such as withdrawal and hospitalization. This before and after study evaluated the impact of the VA’s Opioid Safety Initiative (OSI) on characteristics and prescribing practices. Results indicate that length of tapering period increased, and mortality risk decreased following OSI implementation.
Heesen M, Steuer C, Wiedemeier P, et al. J Patient Saf. 2022;18:e1226-e1230.
Anesthesia medications prepared in the operating room are vulnerable to errors at all stages of medication administration, including preparation and dilution. In this study, anesthesiologists were asked to prepare the mixture of three drugs used for spinal anesthesia for cesarean section. Results show deviation from the expected concentration and variability between providers. The authors recommend all medications be prepared in the hospital pharmacy or purchased pre-mixed from the manufacturer to prevent these errors. 
Varady NH, Worsham CM, Chen AF, et al. Proc Natl Acad Sci USA. 2022;119:e2210226119.
Safe prescribing dictates that prescriptions should only be written for the patients who are intended to use the prescribed medications. Using claims data, this analysis identified a high rate of opioid prescriptions written for and filled by the spouses of patients undergoing outpatient surgery (who may be unable to fill prescriptions themselves after surgery). Findings suggest intentional, clinically inappropriate prescribing of opioids.
WebM&M Case December 14, 2022

A 62-year-old Spanish-speaking woman presented to the pre-anesthesia area for elective removal of a left thigh lipoma. Expecting a relatively simple outpatient operation, the anesthesiologist opted not to use a Spanish language translator and performed a quick pre-anesthesia evaluation, obtaining her history from the medical record. Unknown to the anesthesiologist, the patient was trying to communicate to him that she had undergone jaw replacement surgery and that her mouth opening was therefore anatomically limited.

WebM&M Case December 14, 2022

A 63-year-old woman was admitted to a hospital for anterior cervical discectomy (levels C4-C7) and plating for cervical spinal stenosis under general anesthesia. The operation was uneventful and intraoperative neuromonitoring was used to help prevent spinal cord and peripheral nerve injury. During extubation after surgery, the anesthesia care provider noticed a large (approximately 4-5 cm) laceration on the underside of the patient’s tongue, with an associated hematoma.

Wani MM, Gilbert JHV, Mohammed CA, et al. J Patient Saf. 2022;18:e1150-e1159.
The WHO surgical safety checklist has been implemented in healthcare systems around the world. This scoping review identified five categories of barriers to successful implementation of the WHO checklist (organizational-, checklist-, technical-, and implementation barriers, as well as individual differences). The authors outline recommendations for researchers, hospital administrators, and operating room personnel to improve checklist implementation.  
Clark J, Fera T, Fortier CR, et al. Am J Health Syst Pharm. 2022;79:2279-2306.
Drug diversion is a system issue that has the potential to disrupt patient access to safe, reliable medications and result in harm. These guidelines offer a structured approach for organizations to develop and implement drug diversion prevention efforts. The strategies submitted focus on foundational, organizational, and individual prevention actions that target risk points across the medication use process such as storage, prescribing, and waste disposal.

Arna D, ed. Curr Opin Anaesthesiol. 2022;35(6):710-737.

Safety challenges in anesthesiology and perioperative care are high-risk situations. This segment of a reoccurring special section covers strategies for improvement such as use of databases to monitor safety, expansion of safety improvement efforts to perioperative care, and cognitive aid use enhancement.
Carmack A, Valleru J, Randall KH, et al. Jt Comm J Qual Patient Saf. 2023;49:3-13.
Retained surgical items (RSI) are a never event, a serious and preventable event. After experiencing a high rate of RSIs, this United States health system implemented a bundle to reduce RSI, improve near-miss reporting, and increase process reliability in operating rooms. The bundle consisted of five elements: surgical stop, surgical debrief, visual counters, imaging, and reporting.

Meyer TA. Anesthesiology News. October 31, 2022.

Medication use in the surgical environment is complex and high-risk. This article describes steps toward the implementation of medication safety process improvement programs for the operating room. Important steps discussed include assessment, analysis, planning, and implementation.
Shawahna R, Jaber M, Jumaa E, et al. J Patient Saf. 2022;18:e1047-e1060.
Medication errors in pediatric anesthesiology are common and largely preventable. This scoping review characterizing medication errors in pediatric anesthesia found that dosing errors were the most common. Recommendations to minimize or prevent medication errors in pediatric anesthesia commonly related to improving medication administration and documentation.
Lusk C, Catchpole K, Neyens DM, et al. Appl Ergon. 2022;104:103831.
Tall Man lettering and color-coding of medication syringes provide visual cues to decrease medication ordering and administration errors. In this study, an icon was added to the standard medication label; participants were asked to identify four medications, with and without the icon, from pre-defined distances. Participants correctly identified the medications with icons slightly more often.

Iyer R, Walker A, eds. Paediatr Anaesth. 2022;32(11):1176-1272.

Progress made in the adoption of infrastructure, Safety I, and Safety II concepts in high- and middle- to lower-income countries around the world support safe pediatric anesthesia care. The articles in this issue illustrate progress made over time in the specialty, highlight areas of focused attention, and examine quality improvement and Lean approaches as success strategies.
WebM&M Case October 27, 2022

A 49-year-old woman presented to an Emergency Department (ED) with abdominal pain nine hours after discharge following outpatient laparoscopic left oophorectomy. The left oophorectomy procedure involved an umbilical port placed using an Optiport visual trocar, a suprapubic port, and two additional ports laterally.

Wu G, Podlinski L, Wang C, et al. Jt Comm J Qual Patient Saf. 2022;48:665-673.
Simulation training is used to improve technical and nontechnical skills among healthcare teams. This study evaluated the impact of a one-hour interdisciplinary in situ simulation training on code response, teamwork, communication and comfort during intraoperative resuscitations. After simulation training, researchers noted improvements in technical skills of individuals and teams (e.g., CPR-related technical skills).

Cooper J, Thomas BJ, Rebello E, et al for the APSF Criminalization of Error Task Force. APSF Newsletter. October 2022; 37(3):80-81

Criminalizing human error can deter the transparency necessary to learn from incidents and improve health care. This position statement articulates the importance of avoiding the criminal prosecution to mistakes to instead focus on system failures to prevent conditions that permit errors to harm patients.
Hebballi NB, Gupta VS, Sheppard K, et al. J Patient Saf. 2022;18:e1021-e1026.
Handoffs from one care team to another present significant risks to the patient if essential patient information is not shared or understood by all team members. Stakeholders at this children’s hospital developed a structured tool for handoff between surgery and pediatric or neonatal intensive care units. Transfer of information and select patient outcomes improved, handoff time was unchanged, and attendance by all team members increased.
Vecchione TM, Agarwal R, Monitto CL. Paediatr Anaesth. 2022;32:982-992.
Appropriate pediatric pain management is an ongoing patient safety concern. This article discusses five categories of errors in pediatric acute pain management and how mitigating cognitive biases can help clinicians anticipate, identify, and avoid these errors.