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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 78 Results
Ivanovic V, Assadsangabi R, Hacein-Bey L, et al. Clin Radiol. 2022;77:607-612.
Radiological interpretation errors can result in unnecessary additional tests, wrong treatment and delayed diagnosis. This study explored the correlation between neuroradiologists’ diagnostic errors and attendance at institutional tumor boards. Results show that higher attendance at tumor boards was strongly correlated with lower diagnostic error rates. The researchers recommend increased and continuous attendance at tumor boards for all neuroradiologists.
de Loizaga SR, Clarke-Myers K, R Khoury P, et al. J Patient Exp. 2022;9:237437352211026.
Parents have reported the importance of being involved in discussions with clinicians following adverse events involving their children. This study asked parents and physicians about their perspectives on inclusion of parents in morbidity and mortality (M&M) reviews. Similar to earlier studies, parents wished to be involved, while physicians were concerned that parent involvement would draw attention away from the overall purpose (e.g., quality improvement) of M&M conferences.
Lazzara EH, Salisbury M, Hughes AM, et al. J Patient Saf. 2022;18:e275-e281.
Morbidity and mortality conferences (MMC) serve as a way for health care teams to discuss adverse events and errors with the goal of improving patient safety. This article presents five recommendations to improve MMC: encourage culture change; allocate ample time for open communication to foster innovative thinking; take a global approach; learn from errors and near misses; and do not just talk the talk, but also walk the walk.
WebM&M Case January 26, 2022

This case involves a 2-year-old girl with acute myelogenous leukemia and thrombocytopenia (platelet count 26,000 per microliter) who underwent implantation of a central venous catheter with a subcutaneous port. The anesthetist asked the surgeon to order a platelet transfusion to increase the child’s platelet count to above 50,000 per microliter. In the post-anesthesia care unit, the patient’s arterial blood pressure started fluctuating and she developed cardiac arrest.

Curated Libraries
September 13, 2021
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, collaborative initiatives, teamwork, and trigger tools.
Serou N, Husband AK, Forrest SP, et al. J Patient Saf. 2021;17:335-340.
Clinicians involved in a medical error may experience emotional distress, shame, and self-doubt. This qualitative study with medical and non-medical operating room staff at five hospitals in the United Kingdom explored support received after involvement in a patient safety incident. Participants were most likely to receive support from their peers after a patient safety incident, but highlighted a lack of institutional-level emotional and professional support and the need to cultivate an organizational culture where seeking support is not perceived as a sign of weakness.
de Vos MS, Hamming JF, Marang-van de Mheen PJ. J Patient Saf. 2021;17:231-238.
Morbidity and mortality (M&M) conferences are a useful tool for teams to investigate and learn from adverse events. In this observational study, researchers interviewed clinicians attending surgical M&M conferences to explore the types, and recurrence of, lessons learned. Clinicians ascribed most lessons to technical or individual-level issues, and observed the challenges to sustaining changes at a systems-level. Researchers suggest M&M formats should shift to a broader focus to implement and sustain lasting system-level improvements.
Boyle FM, Horey D, Siassakos D, et al. BJOG. 2020;128:696-703.
Patients, parents and caregivers play an important role in improving patient safety. Although parents have expressed interest in engaging in perinatal mortality review processes, this international survey of healthcare providers found that less than one-third of respondents (from various types of healthcare facilities) included parents in the review process at their institutions. The authors discuss the potential importance of parental involvement after perinatal mortality to improve care.
Perry MF, Melvin JE, Kasick RT, et al. J Pediatr. 2021;232:257-263.
Diagnostic errors remain an ongoing patient safety challenge and can result in patient harm. This article describes one large pediatric hospital's experience using a systematic methodology to identify and measure diagnostic errors. The quality improvement (QI) project used five domains (autopsy reports, root cause analyses (RCAs), voluntary reporting system, morbidity & mortality conference, and abdominal pain trigger tool) and adjudication by a QI team to identify cases of diagnostic error; Morbidity & mortality conferences, RCAs and abdominal trigger tool identified the majority (91%) of diagnostic errors.   
Leuridan G. Safety Sci. 2020;129:104839.
The author defines ‘work debate spaces’ as organizational spaces that serve as a vehicle for organizational learning, practice changes, and performance improvement. This article discusses the role of formal and informal ‘work debate spaces’ in establishing a culture of safety in critical care settings. Examples of formal and informal spaces include mortality and morbidity (M&M) meetings (formal) and handoffs between shifts (informal).

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.
Sauro K, Ghali WA, Stelfox HT. BMJ Qual Saf. 2019;29:341-344.
This commentary discusses the challenges associated with detecting and measuring adverse events, the limitations of measurement alone, and the existing methodologies that can be leveraged to improve the accuracy of adverse event detection.
WebM&M Case November 27, 2019
Three patients were at the same hospital over the course of a few months for vascular access device (VAD) placement and experienced adverse outcomes. The adverse outcomes of two of them were secondary to drugs given for sedation, while the third patient’s situation was somewhat different. Vascular access procedures are extremely common and are relatively short but may require the use of procedural sedation, which is usually very well tolerated but can involve significant risk, as these cases illustrate.
Berman L, Ottosen M, Renaud E, et al. J Pediatr Surg. 2019;54:1872-1877.
Morbidity and mortality (M&M) conferences are designed to review adverse events. They are one method by which physicians undergo peer review to evaluate their performance and can allow health systems to identify potential avenues for improving patient safety. A survey of pediatric surgeons found that while the M&M participation was high, few believed the process results in practice changes or preventing future events. M&Ms considered most effective had a structured approach, were data driven with loop closure, emphasized multidisciplinary participation, and served as an educational forum.
Koo A, Smith JT. Insights Imaging. 2019;10:68.
Prior research has examined what factors may influence learning from mistakes. Researchers describe their analysis of more than 600 cases discussed at educational radiology conferences over several years. They were able to identify numerous opportunities for improving learning from error, including using positive cases (e.g., near misses or difficult cases in which extra effort helped avert an error) and targeting teaching to address recurrent deficiencies.
Ogunyemi D, Hage N, Kim SK, et al. Jt Comm J Qual Patient Saf. 2019;45:423-430.
The rise in maternal morbidity and mortality is one of the most pressing patient safety issues in the United States. Formal debriefing after adverse events is an important method for analyzing and improving safety. In this study, an academic hospital adopted a systems-based morbidity and mortality conference model to review cases of serious maternal harm and implemented several safety measures (including teamwork training) to address issues that were identified through structured review.
Slomski A. JAMA. 2019;321:1239-1241.
Maternal mortality is a sentinel event that affects mothers and families across a wide range of socioeconomic characteristics. This commentary explores how data collection gaps, medical errors, ineffective treatments, and care coordination weaknesses contribute to preventable maternal death. The author highlights efforts to improve safety in maternity care such as best practice bundles to ensure teams and clinicians are prepared for certain complications.
Eichbaum Q, Adkins B, Craig-Owens L, et al. Diagnosis (Berl). 2019;6:249-257.
Morbidity and mortality (M&M) conferences were traditionally promoted as a strategy to learn from adverse events. Researchers conducted a retrospective review of 49 M&M rounds cases in the pathology department of a single medical center and found that 36% of cases likely involved errors related to cognitive bias.
Durstenfeld MS, Statman S, Dikman A, et al. Am J Med Qual. 2019;34:590-595.
Academic medical centers are working to increase resident engagement in patient safety work. Building on Reason's system failure investigation model, this commentary describes the integration of monthly educational opportunities into actual improvement efforts. Core elements of the program rely on effective case selection, root cause analysis, and resident-led discussion.