Skip to main content

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.

Search All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
PSNet Original Content
Additional Filters
Displaying 1 - 20 of 74 Results
Chen S, Skidmore S, Ferrigno BN, et al. J Thorac Cardiovasc Surg. 2022;Epub Sep 15.
“Second victims” are healthcare providers and support staff involved in an unexpected adverse event and experience continuing psychological harm. While some hospitals provide formal support for “second victims,” it is frequently underutilized. In addition to implementing (and improving) formal support programs, this commentary also encourages a culture of safety and understanding of the 6-stage pathway toward recovery.
Enumah SJ, Sundt TM, Chang DC. J Healthc Manag. 2022;67:367-379.
Hospitals that implement quality improvement initiatives improve patient safety but also incur financial expenses related to implementation, sustainment, and reporting. This study used data from the American Hospital Association and Hospital Compare to evaluate the relationship of financial performance and quality in hospitals performing cardiac surgery. The findings indicate hospitals with lower Patient Safety Indicator 90 (PSI 90) scores had poorer financial performance in the following year.
Ibrahim M, Szeto WY, Gutsche J, et al. Ann Thorac Surg. 2022;114:626-635.
Reports of poor care in the media or public reporting systems can serve as an impetus to overhauling hospitals or hospital units. After several unexpected deaths and a drop in several rating systems, this cardiac surgery department launched a comprehensive quality improvement review. This paper describes the major changes made in the department, including role clarity and minimizing variation in 24/7 staffing.
Arnaoutakis GJ, Ogami T, Aranda‐Michel E, et al. J Am Heart Assoc. 2022;11:e025026.
Missed diagnosis of aortic emergencies can result in patient death, therefore patients with presumed aortic syndromes may be transferred to aortic referral centers. Because interhospital transfers present their own risks, these researchers evaluated emergency transfers of patients who did not ultimately have a diagnosis of acute aortic dissection, intramural hematoma, penetrating aortic ulcer, thoracic aortic aneurysm, or aortic pseudoaneurysm. Approximately 11% of emergency transfers were misdiagnosed, secondary to imaging misinterpretation.
Uramatsu M, Maeda H, Mishima S, et al. J Cardiothorac Surg. 2022;17:182.
Wrong-patient transfusion errors can lead to serious patient harm. This case report describes a blood transfusion error and summarizes the systems issues that emerged during the root case analysis, as well as the corrective steps implemented by the hospital to prevent future transfusion errors. A previous Spotlight Case featured a near-miss transfusion error and strategies for ensuring safe transfusion practices.
Zhang D, Gu D, Rao C, et al. BMJ Qual Saf. 2022;Epub Jun 1.
Clinician workload has been linked with poor patient outcomes. This retrospective cohort study assessed the outcomes for patients undergoing coronary artery bypass graft (CABG) performed as a surgeons’ first versus non-first procedure of the day. Findings suggest that prior workload adversely affected outcomes for patients undergoing CABG surgery, with increases in adverse events, myocardial infarction, and stroke compared to first procedures.
Massart N, Mansour A, Ross JT, et al. J Thorac Cardiovasc Surg. 2022;163:2131-2140.e3.
Surgical site infections and other postoperative healthcare-acquired infections (HAIs) can lead to significant patient morbidity and mortality. This retrospective study examined the relationship between HAIs after cardiac surgery and postoperative inpatient mortality. Among 8,853 patients undergoing cardiac surgery in one academic hospital in France, 4.2% developed an HAI after surgery. When patients developing an HAI were matched with patients who did not, the inpatient mortality rate was significantly greater among patients with HAIs (15.4% vs. 5.7%).
MacLeod JB, D’Souza K, Aguiar C, et al. J Cardiothorac Surg. 2022;17:69.
Post-operative complications can lead to increased length of hospital stay, cost, and resource utilization. This retrospective study compared “fast track” patients (patients extubated and transferred from ICU to a step-down unit the same day as their procedure) and patients who were not fast tracked. Results showed fast track pathways led to a reduction in ICU and overall hospital length of stay and similar post-operative outcomes.
Mariyaselvam MZA, Patel V, Young HE, et al. J Patient Saf. 2022;18:e387-e392.
A retained foreign object can lead to serious clinical consequences and is considered a never event. Researchers analyzed a national patient safety incident database to identify factors contributing to guidewire retention and potential preventative measures. Findings indicate that most retained guidewires are identified after the procedure. The authors suggest that system changes or design modifications to central venous catheter equipment is one approach to prevent guidewire attention.
Morisawa T, Saitoh M, Otsuka S, et al. J Clin Med. 2022;11:640.
Hospital-acquired functional decline can lead to poor health outcomes for frail older adults. This multicenter, prospective cohort study set in Japan assessed the effect of hospital-acquired function decline on post-discharge outcomes among older adults who had undergone cardiac surgery. The study observed poor prognostic outcomes in one-third of patients. Hospital-acquired functional decline was an independent predictor of poor prognosis. The authors encourage hospitals to develop and implement approaches to preventing functional decline in older adults.
Sun LY, Jones PM, Wijeysundera DN, et al. JAMA Netw Open. 2022;5:e2148161.
Previous research identified a relationship between anesthesia handoffs and rates of major complications and mortality compared to patients who had the same anesthesiologist throughout their procedure. This retrospective cohort study including over 102,000 patients in Ontario, Canada, explored this relationship among patients undergoing cardiac surgery. Analyses revealed that anesthesia handovers were associated with poorer outcomes (i.e., higher 30-day and one-year mortality rates, longer hospitalizations and intensive care unit stays) compared with patients who had the same anesthesiologist throughout their procedure.
Boquet A, Cohen T, Diljohn F, et al. J Patient Saf. 2021;17:e534-e539.
This study classified flow disruptions affecting the anesthesia team during cardiothoracic surgeries. Disruptions were classified into one of six human factors categories: communication, coordination, equipment issues, interruptions, layout, and usability. Interruptions accounted for nearly 40% of disruptions (e.g., events related to alerts, distractions, searching activity, spilling/dropping, teaching moment).
Leveson N, Samost A, Dekker SWA, et al. J Patient Saf. 2020;16:162-167.
This article describes the use of a new accident analysis technique (CAST, or Causal Analysis based on Systems Theory), an alternative approach to root cause analysis. The CAST approach is based on the principle that accidents are not only the result of individual system component failures or errors but more generally result due to inadequate enforcement of constraints on the behavior of the system components (i.e., safety constraints enforced by controls, such as checklists).  Many adverse events (AEs) appear to be related to the design of the system involved and not attributable to unsafe individual behavior. This technique can be useful in identifying causal factors to help health care systems learn from mistakes and design systems-level changes to prevent future AEs.

NHS Improvement. Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust. NHS England. March 2020.

In-depth incident investigations provide details of care process examinations to motivate learning and improvement. This report examines cardiac surgery patient mortality at a National Health Service Trust over a 5-year period. It highlights weakness in professionalism at the individual and organization level as a contributor to the preventable patient deaths catalogued over that time.
Zenati MA, Kennedy-Metz L, Dias RD. Semin Thorac Cardiovasc Surg. 2019.
Cognitive engineering (CE) in healthcare explores the environmental complexities and physical demands on providers that may contribute to medical errors. This article discusses cognitive engineering strategies that can be applied to cardiothoracic surgery to improve patient safety. Strategies include automated cognition, team performance sensor-based measurement systems and computer vision for team monitoring.
Axtell AL, Moonsamy P, Melnitchouk S, et al. J Thorac Cardiovasc Surg. 2019.
Physician work hours and fatigue can impact patient safety, particularly among subspecialties focused on high-risk patients. This retrospective cohort study examined outcomes of patients undergoing nonemergent cardiac surgery occurring before or after 3pm. The investigators found no differences in mortality, complications, or length of stay and posit that this may stem from resource availability in these specialized care settings regardless of the time of day.

Gabler E. New York Times. May 31, 2019.

Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.
Chang BH, Hsu Y-J, Rosen MA, et al. Am J Med Qual. 2020;35:37-45.
Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.
Graham AJ, Ocampo W, Southern DA, et al. BMJ Qual Saf. 2019;28:310-316.
This study examined the implementation of a tool integrated into the electronic health record to export surgical discharge data to an adverse event reporting platform. The tool demonstrated high sensitivity and specificity when compared to a chart audit and identified a higher proportion of adverse surgical events than traditional reporting mechanisms. The authors recommend implementation of these automated reporting mechanisms.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica. May 2018-May 2019.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.