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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 50 Results
WebM&M Case December 14, 2022

A 63-year-old woman was admitted to a hospital for anterior cervical discectomy (levels C4-C7) and plating for cervical spinal stenosis under general anesthesia. The operation was uneventful and intraoperative neuromonitoring was used to help prevent spinal cord and peripheral nerve injury. During extubation after surgery, the anesthesia care provider noticed a large (approximately 4-5 cm) laceration on the underside of the patient’s tongue, with an associated hematoma.

Moore T, Kline D, Palettas M, et al. J Nurs Care Qual. 2023;38:55-60.
Fall prevention is a safety priority in hospital settings. This study found that Smart Socks – socks containing pressure sensors that detect when a patient is trying to stand up – reduced fall rates among patients at risk of falls in one hospital’s neurological and neurosurgical department. Over a 13-month period, investigators observed a decreased fall rate (0 per 1000 patient days) among patients wearing Smart Socks compared to prior to intervention implementation (4 per 1000 patient days).
Brösterhaus M, Hammer A, Gruber R, et al. PLoS ONE. 2022;17:e0272853.
Healthcare organizations use trigger tools to identify potential errors or adverse events in the electronic health record (EHR), measure the frequency of errors, and track safety improvements. Three hospitals in Germany conducted a feasibility study of implementing the Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT) in two general surgery units and one neurosurgery unit. Twenty-two feasibility criteria were developed (low-, moderate-, problematic-level of challenge) which may help guide successful implementation of the GTT.
Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. J Patient Saf. 2022;18:e1181-e1188.
Intravenous admixture preparation errors (IAPE) in hospitals are common and may result in harm if they reach the patient. In this before-and-after study, IAPE data were collected to evaluate the safety of a pharmacy-based centralized intravenous admixture service (CIVAS). Compared to the initial standard practice (nurse preparation on the ward), IAPE of all severity levels (i.e., potential error, no harm, harm) decreased and there were no errors in the highest severity level after implementation of CIVAS.

Boodman SG. Washington Post. January 23, 2021.

Misdiagnosis can endure over a long period and delay a correct course of treatment. This news feature shares an example of depression misdiagnosis that masked the true problem of a neurological tumor manifesting in what was seen and treated as a psychological condition. 
WebM&M Case October 28, 2020

A 73-year-old female underwent a craniotomy and aneurysm clipping to resolve a subarachnoid hemorrhage due to a ruptured aneurysm. The neurosurgery resident confirmed the presence of neuromonitoring with the Operating Room (OR) front desk but the neuromonitoring technician never arrived and the surgeon – who arrived after the pre-op huddle – decided to proceed with the procedure in their absence. Although no problems were identified during surgery, the patient emerged from anesthesia with left-sided paralysis, and post-op imaging showed evidence of a new stroke.

Storesund A, Haugen AS, Flaatten H, et al. JAMA Surg. 2020;155:562-570.
This study assessed the impact of combined use of two surgical safety checklists on morbidity, mortality, and length of stay – the Surgical Patient Safety System (SURPASS) is used to address preoperative and postoperative care, and the World Health Organization surgical safety checklist (WHO SSC) is used for perioperative care.  In addition to existing use of the WHO SSC, the SURPASS checklist was implemented in three surgical departments in one tertiary hospital in Norway. Results demonstrated that combined use of these checklists was associated with reduced complications reoperations, and readmissions, but combined use did not impact mortality or length of stay.
Barbanti-Brodano G, Griffoni C, Halme J, et al. Eur Spine J. 2019.
Checklists are one tool for improving communication and reducing risk of adverse outcomes. The World Health Organization Surgical Safety Checklist has been previously studied in various surgical specialties; this study sought to determine its effectiveness in spinal surgeries. The authors conducted a retrospective analysis comparing the incidence of complications pre-checklist and post-checklist in a single center and found a significant reduction in the overall incidence of complications after the introduction of the checklist.
Hall AJ, Toner NS, Bhatt PM. Br J Neurosurg. 2019;33:495-499.
Research has found that checklists can improve patient safety in various surgical specialties but their use in neurosurgery is limited. This single center study implemented a neurosurgical postoperative checklist, which resulted in more patients undergoing a postoperative review and increases in appropriate medication prescribing. 
Westman M, Takala R, Rahi M, et al. World Neurosurg. 2019.
Checklists have been shown to improve patient safety in various surgical specialties but this systematic review found that evidence of their impact in neurosurgery is still limited given emerging technologies such as robotics and artificial intelligence. Studies with larger neurosurgical patient populations, as well as in relation to robotic neurosurgery, are needed to understand the impact of checklists in neurosurgery.
WebM&M Case August 8, 2019
A woman with a history of prior spine surgery presented to the emergency department with progressive low back pain. An MRI scan of T11–S1 showed lumbar degenerative joint disease and a small L5–S1 disc herniation. She was referred for physical therapy and prescribed muscle relaxant, non-steroidal anti-inflammatories, and pain relievers. Ten days later, she presented to a community hospital with fever, inability to walk, and numbness from the waist down. Her white blood cell count was greater than 30,000 and she was found to be in acute renal and liver failure.
Walter FM, Penfold C, Joannides A, et al. Br J Gen Pract. 2019;69:e224-e235.
This qualitative study of 39 patients with a recent diagnosis of brain tumor found that many had multiple primary care visits prior to diagnosis, raising concern for missed opportunities for diagnosis. Patients reported more prompt diagnosis when their primary care physician elicited a more comprehensive history including subtle cognitive changes. The authors conclude that better public awareness of symptoms could prompt more timely diagnosis of brain tumors.
Beil L. ProPublica. October 2, 2018.
This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted in patient harm. A past PSNet perspective explored the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
Howard BM, Holland CM, Mehta C, et al. JAMA Surg. 2018;153:313-321.
Overlapping surgery refers to the practice of surgeons scheduling two procedures performed on different patients concurrently. This practice has raised safety concerns in light of news investigations, which prompted a government inquiry into concurrent surgery policies. This single-center retrospective study of 2275 neurosurgery cases at an academic medical center compared overlapping to nonoverlapping procedures. The majority of surgeries were overlapping, and rates of morbidity and mortality did not differ between overlapping and nonoverlapping cases. These findings suggest that overlapping surgery can be conducted safely.
Baker M.
Reporting on an incident involving a patient who died after a surgery, this news article discusses potential contributing factors in the incident such as concurrent surgeries and failure to consider patient and family concerns. A past WebM&M commentary highlighted the importance of listening to families when they advocate for patients in the hospital.
Moghavem N, McDonald K, Ratliff JK, et al. Med Care. 2016;54:359-64.
The AHRQ Patient Safety Indicators (PSIs) can identify adverse events in hospital data. This study demonstrated that PSIs were associated with longer hospital stays and increased mortality. Neurosurgery patients were more likely to have PSIs occur than other surgical patients.
Graudins L, Downey G, Bui T, et al. Jt Comm J Qual Patient Saf. 2016;42:86-91.
Administration errors involving high-alert medications have the potential to cause serious patient harm. This commentary discusses one hospital's effort to reduce errors associated with neuromuscular blocking agents. The authors used root cause analysis to identify weaknesses in labeling, storage, and packaging methods, and implemented guidelines to reduce risk of errors involving such medications.
Bina RW, Lemole M, Dumont TM. J Neurosurg. 2016;124:842-8.
Resident duty hours have resulted in the need for medical specialties to design and implement strategies to fulfill service demands while meeting educational goals. Examining the impact of duty hour restrictions for training neurosurgical residents, this review suggests that work hour limits be applied with unique consideration for the needs of distinct specialties.
Bydon M, Abt NB, De la Garza-Ramos R, et al. J NeuroSurg. 2015;122:955-961.
This study used the National Surgical Quality Improvement Program database to compare the outcomes of patients who underwent neurosurgery with only attending physicians versus those that also involved resident physicians. After adjusting for patient characteristics and comorbidities, there were no significant differences in postoperative 30-day morbidity or mortality.