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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 214 Results
Pati AB, Mishra TS, Chappity P, et al. Jt Comm J Qual Patient Saf. 2023;Epub Apr 22.
The World Health Organization (WHO) Surgical Safety Checklist is widely used, but implementation challenges remain. This article describes the development of an electronic version of the surgical safety checklist adapted for use on a personal device, and compared its use against the traditional paper-based checklist. The electronic checklist had 100% use (compared to 98% for the traditional checklist) and significantly higher frequency of completion (100% vs. 27%).
Duffy C, Menon N, Horak D, et al. J Patient Saf. 2023;19:281-286.
Resiliency and proactive safety behaviors can improve safety in the perioperative environment. In this article, the authors describe safety attitudes of perioperative staff after participating in a proactive activity, One Safe Act (OSA). Most participants reported the OSA activity would change their work practices, improve their work unit's ability to deliver safe care, and demonstrate their colleagues' commitment to patient safety.

ACS TQIP Mortality Reporting System Writing Group. J Trauma Acute Care Surg. 2023.

Anonymous case reporting provides opportunities to examine unexpected patient harm instances to pinpoint process changes and enhance learning. This case series shares analysis of adverse events submitted to a trauma center-focused reporting program as tools for improvement. The cases are freely available.
Perspective on Safety April 26, 2023

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.

Moorehead LD. Outpatient Surgery. April 5, 2023.

Retained surgical items (RSIs) are considered “never events” but continue to be a source of patient harm. This article discusses the various factors that increase risk of RSIs and strategies to prevent them, such as a consistent counting process and fostering a culture of safety that encourages speaking up and a non-punitive response to errors.
Duffy C, Menon N, Horak D, et al. JAMA Netw Open. 2023;6:e237621.
Safety-II is a proactive approach to improving patient safety by focusing on what goes right in healthcare. This study describes the use of a novel tool and activity, One Safe Act (OSA), to capture activities performed by perioperative staff that keep patients safe. Eight themes emerged, with the most common theme being routines the staff “always” performed, followed by confirming resource availability.
King CR, Shambe A, Abraham J. JAMIA Open. 2023;6:ooaf015.
Handoffs and transitions of care represent a vulnerable time for patients as important information must be shared and understood by multiple people. This study focuses on postoperative nurse handoffs, specifically regarding situational awareness and anticipatory guidance, and the role artificial intelligence (AI) could play in improving handoffs. Five themes were uncovered, including the importance of situational awareness and associated barriers, how AI could address those barriers, and how AI could result in new/additional barriers.
Dresser S, Teel C, Peltzer J. Int J Nurs Stud. 2023;139:104436.
Understanding how nurses use their clinical judgment in activating early warning systems or rapid response teams is important in improving response to deteriorating patients. Interviews with 20 nurses revealed an overarching sense of responsibility to their patients, eight subthemes including experience, making sense of the data, and a culture of teamwork.
Nasri B-N, Mitchell JD, Jackson C, et al. Surg Endosc. 2023;37:2316-2325.
Distractions in the operating room can contribute to errors. Based on survey responses from 160 healthcare workers, this study examined perceived distractions in the operating room. All participants ranked auditory distractions as the most distracting and visual distractions as the least distracting, but the top five distractors fell into the equipment and environmental categories – (excessive heat/cold, team member unavailability, poor ergonomics, equipment unavailability, and competitive demand for equipment). Phone calls/pagers/beepers were also cited as a common distractor. 
Bloo G, Calsbeek H, Westert GP, et al. J Patient Saf Risk Manag. 2023;28:31-46.
Racial and ethnic minoritized patients frequently have poorer postoperative outcomes. The hospital in this study found the opposite and sought the perspectives of minority and non-minority patients to explore potential contributing factors. Both groups of patients described positive communication with nurses and physicians, trust in the team, and family support. Only one unique factor came up for the ethnic minority patients: having someone, an interpreter, accompany them to the operating room made them feel safe.
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;110:645-654.
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.

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.  
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.