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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 202 Results
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.
WebM&M Case March 15, 2023

This case focuses on immediate-use medication compounding in the operating room and how the process creates situations in which medication errors can occur. The commentary discusses strategies for safe perioperative compounding and the role of standardized processes, such as checklists, to ensure medication safety.

Brooks JV, Nelson-Brantley H. Health Care Manage Rev. 2023;48:175-184.
Effective nurse managers support a culture of safety and improved patient outcomes. This study explores strategies implemented by meso-level nurse leaders - nurse managers between executive leadership and direct care nurses – to enable a culture of safety in perioperative settings. Four strategies were identified: (a) recognizing the unique perioperative management environment, (b) learning not to take interactions personally, (c) developing "super meso-level nurse leader" skills, and (d) appealing to policies and patient safety.
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.
Armstrong BA, Dutescu IA, Tung A, et al. Br J Surg. 2023;Epub Feb 8.
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.
WebM&M Case February 1, 2023

These cases describe the rare but dangerous complication of hematoma following neck surgery. The first case involves a patient with a history of spinal stenosis who was admitted for elective cervical discectomy and cervical disc arthroplasty who went into cardiopulmonary arrest three days post-discharge and could not be intubated due to excessive airway swelling and could not be resuscitated. Autopsy revealed a large hematoma at the operative site, causing compression of the upper airway, which was the suspected cause of respiratory and cardiac arrest.

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.

Marsh KM, Turrentine FE, Schenk WG, et al. Ann Surg. 2022;276:e347-e352.
The perioperative period represents a vulnerable time for patients. This retrospective review of patients undergoing surgery at one hospital over a one-year period concluded that medical errors (including, but not limited to, technical errors, diagnostic errors, system errors, and errors of omission) were strongly associated with postoperative morbidity.
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.  
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.
Tubic B, Finizia C, Zainal Kamil A, et al. Nurs Open. 2023;10:1684-1692.
Interventions to increase patient engagement in safety are receiving increasing attention. In this study, patients were given a safety leaflet containing information about the patient can avoid adverse events during their hospital stay. Participants were overall satisfied about receiving information about their care but noted a lack of communication between healthcare personnel and patients regarding the safety leaflet.
WebM&M Case November 16, 2022

A 61-year-old women with a mechanical aortic valve on chronic warfarin therapy was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. CT imaging revealed two arterial thromboses the right lower extremity and an echocardiogram revealed a thrombus near the prosthetic heart valve. The attending physician ordered discontinuation of warfarin and initiation of a heparin drip.

Harton L, Skemp L. J Nurs Manag. 2022;30:2781-2790.
Nurse leaders play an important role in ensuring a robust patient safety culture. Ten nurse leaders at a United States hospital provided their perspectives on how they ensure a culture of safety on their units. Six overarching themes emerged as well as structural and organizational challenges.
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.

Alagoz E, Saucke M, Arroyo N, et al. J Patient Saf. 2022;18:711-716.
Patients transferring between hospitals have poorer outcomes than directly admitted patients, even when adjusting for other risk factors. In this study, transfer center nurses (TCN) described communication challenges that may influence patient outcomes. Themes included referring clinicians providing incomplete information, competing clinical demands, or fear of the transfer request being denied.
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).
Girotra S, Jones PG, Peberdy MA, et al. Circ Cardiovasc Qual Outcomes. 2022;15:e008901.
Rapid response teams (RRTs) have been implemented at hospitals worldwide, despite mixed results in their effectiveness. The aim of this study was to compare expected mortality rates with mortality rates following RRT implementation, adjusted for hospital case mix. Of 56 hospitals that participated in this project and had complete data, only four showed lower-than-expected mortality rates and two showed higher-than-expected mortality, suggesting RRT may not reduce mortality rates as much as earlier studies have reported.
Liu SI, Shikar M, Gante E, et al. Crit Care Nurse. 2022;42:33-43.
Lack of communication between providers can contribute to failure to rescue. Following a series of deaths due in part to not identifying clinical deterioration in a timely manner and/or not escalating care, this surgical intensive care unit (SICU) implemented an interdisciplinary quality improvement intervention. The intervention consisted of educating nurses on conditions necessitating escalation, multidisciplinary rounds with night staff, and an escalation document in the electronic health record (EHR).
Giuliano KK, Blake JWC, Bittner NP, et al. J Patient Saf. 2022;18:553-558.
Intravenous (IV) smart pumps can improve medication administration safety, but usability issues can compromise that safety. This study compared actual use of smart pumps to the manufacturer’s requirements for operation. Adherence to requirements was low and the authors present several recommendations to smart pump manufacturers. The Institute for Safe Medication Practices issued guidelines for safe use of smart pumps that address several of these safety concerns.