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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On Patient Safety.

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Järvinen TLN, Rickert J, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.

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Diagnostic Errors Case Studies

January 19, 2023

The Primary-Care Research in Diagnosis Errors (PRIDE) Learning Network was a Boston-based national effort to improve diagnostic safety. Hosted by the State of Massachusetts’ Betsy Lehman Center, it was led by the Harvard Brigham and Women’s Center for Patient Safety Research and Practice with funding from the Gordon and Betty Moore Foundation. ...

Sustained improvement in quality of patient handoffs after orthopaedic surgery I-PASS intervention.

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Stenquist DS, Yeung CM, Szapary HJ, et al. J Am Acad Orthop Surg Glob Res Rev. 2022;6:e22.00079.

The I-PASS structured handoff tool has been widely implemented to improve communication during handoffs and patient transfers. In this study, researchers modified the I-PASS tool for use in orthopedic surgery and assessed the impact on adverse clinical outcomes. After 18 months, there was sustained adherence to the tool and the quality of handoffs improved, but no notable changes in clinical outcomes were identified.

Does seasonal variation in orthopaedic trauma volume correlate with adverse hospital events and burnout?

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Waldron J, Denisiuk M, Sharma R, et al. Injury. 2022;53:2053-2059.

Increases in clinician workload can contribute to burnout. This study explored seasonal variation in workload in an orthopedic trauma service at one Level 1 trauma center. Findings indicate that workload was highest in the summer months and correlated with resident sleepiness scores. The study team also found that patient safety events were highest during the summer, but these were not correlated with increased workload.

Trial and error: learning from malpractice claims in childhood surgery.

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Prieto JM, Falcone B, Greenberg P, et al. J Surg Res. 2022;279:84-88.

Hospitalized children are vulnerable to patient safety risks. Using a large malpractice claims database, researchers found that a wide range of pediatric surgical specialties – including orthopedics, general surgery, and otolaryngology – are most frequently associated with malpractice lawsuits. The study identified several potentially modifiable factors (i.e., patient evaluations, technical performance, and communication) that can lead to improvements in pediatric surgical safety.

Feelings of trust and of safety are related facets of the patient's experience in surgery: a descriptive qualitative study in 80 patients.

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Occelli P, Mougeot F, Robelet M, et al. J Patient Saf. 2022;18:415-420.

Understanding patient experience can provide key insights about safety culture. This qualitative study of 80 adult patients concluded that patients’ perspectives of surgical safety are closely tied to the degree of trust they have in their surgeons; this trust is based on the patient’s relationship with their surgeon, communication style, and the patient’s experience during perioperative consultation.

Implicit racial bias in pediatric orthopaedic surgery.

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Guzek R, Goodbody CM, Jia L, et al. J Pediatr Orthop. 2022;42:393-399.

Research has demonstrated inequitable treatment of racially minoritized patients resulting in poorer health outcomes. This study aimed to determine if implicit racial bias impacts pediatric orthopedic surgeons’ clinical decision making. While pediatric orthopedic surgeons showed stronger pro-white implicit bias compared to the US general population (29% vs. 19%), the bias did not appear to affect decision making in clinical vignettes.

Outcomes and patient safety in overlapping vs. nonoverlapping total joint arthroplasty: a systematic review and meta-analysis.

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Malahias M-A, Antoniadou T, Jang SJ, et al. J Am Acad Orthop Surg. 2021;29:e1387-e1395.

Previous research has raised concerns about safety risks associated with overlapping surgery, defined as two procedures performed concurrently, but where critical surgical portions of each procedure occur at different times. Based on a meta-analysis of six articles, the authors of this systematic review found that rates of surgical complications readmissions were similar among overlapping and nonoverlapping surgery in patients undergoing total joint arthroscopy.

Clinically significant medication errors in surgical units detected by clinical pharmacist: a real-life study.

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Renaudin P, Coste A, Audurier Y, et al. Basic Clin Pharmacol Toxicol. 2021;129:504-509.

Pharmacists play an essential role in medication safety through practices such as medication reconciliation and best possible medication history. This observational study found that 20% of patients presenting to surgical units at one French hospital over a two-month period had a medication error. Pharmacists intervened and resolved medication errors related to untreated indications, subtherapeutic dosages, and prescriptions without an indication.

There is an app for that: mobile technology improves complication reporting and resident perception of their role in patient safety

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Patient Safety Innovation September 29, 2021

Morbidity and mortality (M&M) conferences are standard components of medical training programs yet medical residents underutilize incident reporting systems that feed into M&M conferences.

The Consequences of Miscommunication Regarding a Possible Artifact

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WebM&M Case June 30, 2021

A 52-year-old man complaining of intermittent left shoulder pain for several years was diagnosed with a rotator cuff injury and underwent left shoulder surgery. The patient received a routine follow-up X-ray four months later.

How satisfied are patients and surgeons with telemedicine in orthopaedic care during the COVID-19 pandemic? A systematic review and meta-analysis.

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Chaudhry H, Nadeem S, Mundi R. Clin Orthop Relat Res. 2021;479:47-56.

The COVID-19 pandemic has dramatically increased the use of telehealth across various medical specialties.This systematic review did not identify any differences in patient or surgeon satisfaction or patient-reported outcomes with telehealth for orthopedic care delivery as compared to in-person visits.However, the authors note that the included studies did not adequately capture or report safety endpoints, such as complications or missed diagnoses.

Too Many Cooks in the Kitchen

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WebM&M Case August 26, 2020

A 40-year-old man with multiple comorbidities, including severe aortic stenosis, was admitted for a pathologic pelvic fracture (secondary to osteoporosis) after a fall. During the hospitalization, efforts at mobilization led to a second fracture of the left femoral neck The case describes deviations in the plan for management of anesthesia and postoperative care which ultimately contributed to the patient’s death.

Pain Alleviation Toolkit.

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American Society of Anesthesiologists, American Academy of Orthopaedic Surgeons. March 12, 2020.

Communication and shared decision-making are fundamental tactics to guide clinical team and patient efforts to minimize the potential for prescription opioid misuse. This tool kit includes modules for providers that outline practice and communication strategies to help with postoperative pain. Patient and family materials in the kit focus on safe medication disposal and instructions for tracking pre- and post-surgery pain levels.

Spinal surgery complications: an unsolved problem-Is the World Health Organization Safety Surgical Checklist an useful tool to reduce them?

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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.

Spinal Epidural Abscess

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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.

If You Say So: Taking a Syringe at Face Value in the Operating Room

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WebM&M Case June 1, 2019

During surgery for a forearm fracture, a woman experienced a drop in heart rate to below 50 beats per minute. As the consultant anesthesiologist had stepped out to care for another patient, the resident asked the technician to draw up atropine for the patient. When the technician returned with an unlabeled syringe without the medication vial, the resident was reluctant to administer the medication, but did so without a double check after the technician insisted it was atropine. Over the next few minutes, the patient's blood pressure spiked to 250/135 mm Hg.

Hip Fractures in Older Patients: the Case for Geriatrics Comanagement

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WebM&M Case April 1, 2019

An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service, with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath.

Clinical impact and economic burden of hospital-acquired conditions following common surgical procedures.

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Horn SR, Liu TC, Horowitz JA, et al. Spine (Phila Pa 1976). 2018;43:E1358-E1363.

This retrospective review of National Surgical Quality Improvement Program data on hospital-acquired conditions following elective spine surgery found that 3% of these cases had at least one hospital-acquired condition. The most common conditions were surgical site infection, followed by urinary tract infection and venous thromboembolism, all well-recognized conditions with known evidence-based prevention strategies.

Safety of overlapping inpatient orthopaedic surgery: a multicenter study.

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Dy CJ, Osei DA, Maak TG, et al. J Bone Joint Surg Am. 2018;100:1902-1911.

Overlapping surgery is a controversial practice in which an attending surgeon performs more than one procedure concurrently. This retrospective cohort of overlapping orthopedic surgeries across five academic institutions found no differences between complication rates for overlapping versus nonoverlapping procedures. The authors recommend individualizing decisions regarding overlapping surgeries.

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