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.
Surgical complications can result in unexpected situations requiring immediate action to save patients. This brief summarizes gaps in failure to rescue processes and shares recommendations for health systems, certification programs and professional organizations to motivate improvement.
Oakbrook Terrace, IL: Joint Commission: October 2019.
Inpatient suicide is increasing as a safety concern. This case analysis offers two levels of examination of a hypothetical patient suicide: one that outlines points of failure in the patient’s care and the other that shares strategies to prevent the event from occurring.
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis describes the prevalence of pregnancy-related death and areas of concern during pregnancy, at delivery, and up to a year postpartum. It reports that 60% of these deaths are preventable and provides suggestions for families, clinicians, and systems to reduce risks.
Delayed diagnosis of sepsis can have serious consequences. This article and accompanying set of infographics spotlight the importance of prompt identification and treatment of sepsis and suggest how providers, organizations, patients, and families can help improve recognition of sepsis.
Health care–associated infections (HAI) are a worldwide patient safety problem. This article and accompanying set of infographics spotlight the importance of addressing HAIs and provide updates on improvements associated with better use of catheters, appropriate patient isolation, and increased vigilance to reduce the risks of antibiotic-resistant infections.
This infographic provides information about adverse drug events, including how frequently and where they occur and strategies to reduce risk of such errors (e.g., computerized provider order entry and barcode medication administration).
Green MJ, Rieck R. Ann Intern Med. 2013;158:357-61.
This piece uses a graphic novel format to depict a story of a diagnostic error that resulted in a patient’s death. The attention-grabbing design is an innovative method for demonstrating the context and emotional aspects related to an adverse event. The story implicitly illustrates the hidden curriculum of medical training that often rewards trainee autonomy and places retrospective blame on individuals. The final frame closes with the author reflecting on how this adverse event had a lasting effect on his psyche - a well-recognized phenomenon known as the second victim of a medical error. A prior AHRQ WebM&M perspective explored many issues related to diagnostic errors.
Nagpal K, Arora S, Abboudi M, et al. Ann Surg. 2010;252:171-6.
This qualitative study interviewed 18 providers and found that postoperative handovers are informal, unstructured, and fraught with inconsistent and incomplete information transfer. These data were used to develop and validate a formal handover protocol. Prior studies have used insights from Formula One auto racing to inform improvement strategies for postoperative handoffs, and the World Health Organization's Surgical Safety Checklist explicitly emphasizes structured handoffs at the time of patient transfer from the operating room to the postoperative area.
Anderson E, Thorpe L, Heney D, et al. Med Educ. 2009;43:542-52.
This study found that exposing students to a team-based patient safety event increased their knowledge of safety principles and also added value above that of learning only with other medical students.
Donaldson N, Shapiro S, Scott M, et al. J Nurs Adm. 2009;39:176-81.
Rapid response teams (RRTs) have proven to be very popular among bedside nursing staff, contributing to their widespread implementation despite equivocal evidence of clinical benefits. This study carried out interviews with nurses, chief nursing officers, and RRT members at 18 hospitals to obtain insights on how to successfully implement RRTs. Themes that predicted successful implementation included clear organizational support for the RRT, support for bedside nurses when the team is called, and less resistance from physicians to using the RRT.
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