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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 4262 Results
Montalmant KE, Ettinger AK. J Racial Ethn Health Disparities. 2023;Epub Nov 13.
The increased risk of maternal morbidity and mortality among Black women in the United States is a patient safety and public health crisis. This literature review of 42 articles highlights the importance of cultural competence and disparities training for obstetric providers to reduce maternal mortality and morbidity among Black women. The authors also highlight the need for increased awareness regarding the increased risk of cardiovascular diseases among pregnant Black women.

Dwyer D, See P. ABC News. November 28, 2023.

Lack of respect for the concerns of patients and sensitivity to their situation detract from their safety and trust in the health care system. This story relates firsthand experience of maternal mistreatment of those harmed while receiving care.
Ahmed M, Suhrawardy A, Olszewski A, et al. J Am Acad Orthop Surg. 2023;Epub Sep 19.
Overlapping surgeries, where one attending surgeon supervises two surgeries with noncritical portions occurring simultaneously, are generally considered as safe as non-overlapping surgeries. This review identified 11 studies into safety outcomes of overlapping orthopedic surgeries involving 34,494 overlapping surgeries. Consistent with prior research, although overlapping surgeries tended to have increased surgical times, short-term outcomes were no different than non-overlapping; one study showed increased risk for adverse events at one year. The authors suggest future research into overlapping robotic-assisted surgeries.
Williams C. Emerg Nurse. 2023;31:34-41.
Overcrowding in the emergency department (ED) and boarding can place patients at increased risk for adverse events. This article outlines how ED overcrowding occurs and provides several approaches to mitigate risks and enhance patient safety in overcrowded EDs, such as checklists, huddles, and resource allocation.
Etheridge JC, Moyal-Smith R, Yong TT, et al. JAMA Surg. 2023;Epub Nov 15.
Surgical safety checklists have been credited with improving perioperative patient outcomes, but numerous studies have shown implementation to be variable across settings and surgical specialties. This study aimed to redesign and reimplement the surgical safety checklist in two academic hospitals. Item completion and fidelity improved after reimplementation and exploratory analysis suggests improved patient outcomes (e.g., serious complications).
WebM&M Case November 30, 2023

A 67-year-old man with well-controlled type 2 diabetes mellitus underwent elective cardiac resynchronization and defibrillator device (CRT-D) implantation. The procedure was successful and he was discharged the next day with instructions to resume his prior medications, including empagliflozin. He presented to the emergency department the following day where he was diagnosed with euglycemic diabetic ketoacidosis (eDKA) and he was transferred to the intensive care unit (ICU) for insulin infusion.

WebM&M Case November 30, 2023

A 38-year-old woman with class 3 obesity required removed of a gastric balloon under general anesthesia. She required a relatively large dose of rocuronium for endotracheal intubation, and she was given intravenous sugammadex (200 mg) at the end of the procedure to reverse the neuromuscular block. A quantitative neuromuscular block monitor was not used, but reliance was placed on clinical signs. Shortly after arrival in the post-anesthesia care unit, she couldn’t move or open her eyes and became jittery with low oxygen saturation.

WebM&M Case November 30, 2023

An 81-year-old man was admitted to the intensive care unit (ICU) with a gastrointestinal bleed and referred for a diagnostic colonoscopy. The nurse preparing the patient for the colonoscopy mistakenly selected a jug of dialysis liquid rather than a polyethylene glycol solution commonly used to clean the colon for colonoscopy. When the barcode on the jug of dialysis liquid did not scan, the nurse called the hospital pharmacy for assistance and was provided a new barcode via a tube system.

WebM&M Case November 29, 2023

This case describes a 55-year-old woman who sustained critical injuries after a motor vehicle crash and had a lengthy hospitalization. On hospital day 30, a surgeon placed a percutaneous endoscopic gastrostomy (PEG) tube in the intensive care unit (ICU) after computed tomography (CT) scan showed no interposed bowel between the stomach and the anterior abdominal wall.  After the uncomplicated PEG placement, the surgeon cleared the patient’s team to advance tube feeds as tolerated.

Ravindran S, Matharoo M, Rutter MD, et al. Endoscopy. 2023;Epub Sept 18.
Understanding the influence of human factors on team and system performance can help safety professionals identify opportunities for improvement. In this study, researchers used a large, centralized incident reporting database in the United Kingdom to examine the human factors contributing to non-procedural endoscopy-related patient safety incidents. Based on Human Factors Analysis and Classification System coding, decision-based errors were the most common factor contributing to incidents, but other contributing factors were also identified, including lack of resources and ineffective team communication.
Roussel M, Teissandier D, Yordanov Y, et al. JAMA Intern Med. 2023;Epub Nov 6.
Overcrowding in the emergency department (ED) can result in long wait times to be seen or admitted, as well as placing patients at increased risk of adverse events. In this prospective study, researchers compared the risk of in-hospital mortality among older patients who spent a night in the ED waiting for admission to the hospital versus older patients who were admitted to the hospital before midnight. Findings indicate that patients who spent an overnight in the ED had a higher in-hospital mortality rate, increased risk of adverse events, and longer length of stay; this risk was exacerbated for patients with limited functional status.
Gogalniceanu P, Kunduzi B, Ruckley C, et al. Am J Surg. 2023;Epub Sep 5.
Healthcare has borrowed many safety practices from aviation such as checklists, crew resource management, and safety culture. In this study, interviews with aviation experts identify non-technical skills that leaders require in a safety culture environment which the authors adapt for surgical leaders. The core attribute was "humble confidence," with three additional domains: management of risk, management of opportunity, and management of people. The authors developed the Safety Leadership Assessment Matrix (SLAM) to assess these non-technical skills in surgeon leaders.
Samost-Williams A, Rosen R, Cummins E, et al. Jt Comm J Qual Patient Saf. 2023;Epub Oct 15.
Team-based morbidity and mortality conferences (TBMMs) involve multidisciplinary or interdisciplinary teams in discussions about complex cases and medical errors. This survey of 1,466 perioperative health care professionals found positive perceptions of TBMMs and traditional Morbidity and Mortality Conferences, but identified several barriers to effective implementation of TBMMs, including unsupportive leadership and fear of professional consequences.
Liepelt S, Sundal H, Kirchhoff R. BMC Health Serv Res. 2023;23:1224.
Root cause analysis (RCA) is a frequently used, and sometimes mandatory, method to investigate sentinel events. In this study, members of an RCA committee were interviewed before and after an RCA investigation to elicit their experiences and assess compliance with the Norwegian RCA process. Organizational factors and team composition presented challenges, particularly the inclusion of staff closely involved with the incident under investigation.

Anaesth Intensive Care. 2023;51(6):372-421.

Centralized de-identified reports of patient safety events serve a core purpose for learning and improvement. This article collection contains research drawn from the Australian/New Zealand webAIRS database. Data reviewed include cesarean and pediatric regional anesthesia incidents submitted to webAIRS over a 13-year period.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.

Maternal health care is rapidly emerging as a high-risk service that is vulnerable to communication, equity, and diagnostic challenges. This report examines the role of disparities in care across the maternal care continuum and strategies to drive diagnostic improvement such as care bundles, midwives, and health information technology. This publication is from a series of programs and resultant publications on improving diagnostic excellence.
Lim PJH, Chen L, Siow S, et al. Int J Qual Health Care. 2023;35:mzad086.
Surgical safety checklists (SCC) are utilized around the world, but checklist completion at the operating room level remains inconsistent. This review summarizes facilitators and barriers to completion. Resistance or endorsement at the individual surgeon level remains a significant factor in SSC completion. Early inclusion of frontline staff in evaluation and implementation supported increased use.
MohammadiGorji S, Joseph A, Mihandoust S, et al. HERD. 2023;Epub Aug 8.
Well-designed workspaces minimize disruptions and distractions. This review and study describes several important ways to improve the anesthesia workspace in the operating room. Recommendations include demarcating an anesthesia zone with adequate space for equipment and storage and that restricts unnecessary staff travel into and through the zone. Each recommendation includes an illustrative diagram, explains its importance, and offers methods to achieve it.

Arnal-Velasco, D, ed. Curr Opin Anaesthesiol. 2023;36(6):649-705.

Adoption of new ideas is necessary to create safety in the perioperative environment. This collection of reviews illustrates relationships and tensions between technology, human factors and safety management that create the sociotechnical system within which technology is used to deliver anesthesia. Topics covered include artificial intelligence, decision making and perioperative deterioration.