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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 28 Results

ISMP Medication Safety Alert!: Acute Care Edition. December 1, 2022;27(24):1-3.

Look-alike medications are vulnerable to wrong route and other use errors. This article examines the potential for mistaken application of ear drops into eyes. Strategies highlighted to reduce this error focus on storage, dispensing, administration, and patient education.
WebM&M Case October 27, 2021

A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution.

DeRosier JM, Hansemann BK, Smith-Wheelock MW, et al. Jt Comm J Qual Patient Saf. 2019;45:680-685.
Researchers used failure mode and effects analysis to examine intraocular lens implantation. They report uncovering many potential failure modes or safety vulnerabilities and extensive variation in how this procedure is conducted. The authors recommend standardization, changes to equipment and workflows, and quality assurance through direct observation in order to enhance safety.
Ashfaq HA, Lester CA, Ballouz D, et al. JAMA Ophthalmol. 2019.
This study examined the concordance between structured medication lists in the electronic health record and unstructured physician progress notes for antibiotic medications being used to treat keratitis, an eye infection. Researchers found that 23% of prescribed medications differed between the progress note and the structured medication list, highlighting the need for and the challenges in conducting medication reconciliation.
Shen C, Nguyen M, Gregor A, et al. JAMA Ophthalmol. 2019;137:690-692.
This study entered 42 validated clinical vignettes for eye diseases into an online symptom checker. As with prior studies, the performance of the online symptom checker in producing the correct diagnosis was suboptimal. The authors suggest that current performance of symptom checkers is not sufficient for timely and accurate diagnosis of ophthalmologic conditions.
Neily J, Soncrant C, Mills PD, et al. JAMA Netw Open. 2018;1:e185147.
The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.
van der Heijde R; Deichmann D.
Aviation continues to provide inspiration for patient safety innovation. This commentary describes a 10-minute team huddle exercise which involves team members rating their own mood status and the leader asking if there are any contextual concerns. In addition, two team members select "knowledge cards" that either test the person's knowledge or assign the person to proactively watch for improvement opportunities during the shift. The results encouraged sharing, situational awareness, and team building.
Campbell RJ, El-Defrawy SR, Gill SS, et al. JAMA Ophthalmol. 2019;137:58-64.
Prior work has demonstrated that surgical outcomes differ depending on individual practitioner skill, and concerns have been raised regarding the need to assess skills of aging physicians. This study examined whether cataract surgery outcomes differ for late-career ophthalmologists, defined as those who completed medical school at least 25 years ago, compared to mid-career ophthalmologists, who completed medical school 15 to 25 years ago. This secondary data analysis of all single-eye cataract surgeries performed in Ontario between 2009 and 2013 found that almost 30% of procedures were performed by late-career practitioners. Overall, adverse surgical events did not differ by career stage, although very small increases in risk of two specific complications—dropped lens fragment and endophthalmitis, a surgical site infection—were observed. These results suggest that cataract surgery by late-career ophthalmologists does not pose a high-priority safety hazard.
Hussain A, Oestreicher J. Surv Ophthalmol. 2018;63:119-124.
Flawed decision-making influences the effectiveness of care on many levels. This review discusses cognitive shortcuts and biases that contribute to diagnostic error. The authors explore how and when these biases occur in opthalmology. Strategies to avoid decision-making errors include cognitive debiasing and heuristic examination.
Fathy CA, Pichert JW, Domenico H, et al. JAMA Ophthalmol. 2018;136:61-67.
Patient complaints are associated with increased malpractice risk. This retrospective cohort study of more than 1300 ophthalmologists sought to determine whether ophthalmologist age was linked to likelihood of receiving unsolicited patient complaints. The authors found that unsolicited patient complaints occur less frequently among older ophthalmologists.
Patel S, Sternberg P. JAMA Ophthalmol. 2017;135:1216-1220.
High-risk prescribing practices contribute to the widespread use of opioids. Analyzing Medicare data, this study found that most ophthalmologists wrote fewer than 10 opioid prescriptions per year, but a small group, concentrated in the Southern states, wrote more than 100 prescriptions annually. An Annual Perspective reviewed problematic prescribing practices that likely contribute to adverse events and described some promising practices to foster safer opioid use.
Custer PL, Fitzgerald ME, Herman DC, et al. Ophthalmology. 2016;123:S40-5.
Efforts to reduce medical errors in ophthalmology often focus on cataract surgery, a high-volume procedure. This commentary explores how a culture of safety affects ophthalmic care, including its influence on error disclosure, teamwork, and failure analysis. The authors also describe initiatives that integrate core safety concepts into professional development programs for the specialty.
Kowalczyk L.
Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery center, this news article describes how factors such as production pressure and insufficient assessment of contract anesthesiologists' qualifications can contribute to adverse events in outpatient surgery.
Lee BS, Gallagher TH. Am J Ophthalmol. 2014;158:1108-1110.e2.
This commentary spotlights elements of ophthalmology practice that can influence error disclosure, particularly the prevalence of patients receiving care from optometrists outside the hospital environment with no central reporting mechanism.
Pikkel D, Sharabi-Nov A, Pikkel J. Risk Manag Healthc Policy. 2014;7:77-80.
In this study, cataract surgeons were asked to identify the correct eye for surgery when given the patient's name only, and again while looking at the patient's face. The surgeons answered incorrectly approximately a quarter of the time, arguing for the importance of preoperative time outs to avoid wrong-site surgery.
WebM&M Case December 1, 2011
A woman presented to the emergency department with an eyelid laceration, which was sutured without complication. Her visual acuity was not formally tested and ophthalmology was not consulted. Ten days later, she presented with eye pain and poor vision. Ophthalmologist evaluation revealed a ruptured globe requiring surgical repair.