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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 32 Results
Stone A, Jiang ST, Stahl MC, et al. JAMA Otolaryngol Head Neck Surg. 2023;149:424-429.
Identifying and classifying adverse events is an important, yet often challenging, component of incident reporting. This article describes the development and testing of a novel Quality Improvement Classification System (QICS) designed to incorporate adverse events in both inpatient and outpatient settings across medical and surgical specialties in order to capture a broader range of outcomes related to patient care, including organizational issues, near-miss events, and expected deviations from ideal outcomes of surgery.
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.

Otolaryngol Head Neck Surg. 2018-2023.

Otolaryngology-head and neck surgery is vulnerable to wrong site errors and other challenges present in surgical care. This series of articles highlights key areas of importance for the specialty as they work to enhance patient safety. The latest 2023 installment covers psychological safety.
Cramer JD, Balakrishnan K, Roy S, et al. OTO Open. 2020;4:2473974X2097573.
Various surgical specialties have implemented surgical checklists to improve patient safety outcomes. In this survey of 543 otolaryngologists, surgical safety checklists were widely used, but intraoperative adverse events continue to occur. The most common adverse events reported were medication errors, wrong site/patient/procedure events, and retained surgical items.
Stanisce L, Ahmad N, Deckard N, et al. Otolaryngol Head Neck Surg. 2019;160:1003-1008.
This pre–post study found that implementation of relative value unit–based payment in a head and neck surgery practice resulted in a higher volume of procedures. The incidence of adverse outcomes, including postoperative hospitalizations, infections, unplanned return surgeries, and emergency department visits, did not change. The authors conclude that the change in payment structure did not impact surgical safety.

Shah RK, ed. Otolaryngol Clin North Am. 2019;52:1-194.

Articles in this special issue apply safety concepts to reducing preventable patient harm in otolaryngology. The reviews highlight systems science, collaboration, leadership models, and patient experience as important to moving safety innovation forward in this specialty.
Tseng YW, Vedula S, Malpani A, et al. JAMA Facial Plast Surg. 2019;21:104-109.
This prospective cohort study examined the association between self-rated daytime sleepiness among trainee surgeons and attending surgeon–rated intraoperative technical skill. Higher ratings of sleepiness were associated with worse technical skills, echoing concerns about procedures performed by sleep-deprived surgeons.
Roberson DW, Kirsh ER. Otolaryngol Clin North Am. 2019;52:1-9.
High-reliability organizations have developed methods for achieving safety despite hazardous conditions. This review summarizes the systems science, organizational structure, and interpersonal working methods that enable high-risk industries like health care to practice reliably and learn from mistakes.

Malekzadeh S, ed. Otolaryngol Clin North Am. 2017;50(5):xv-xviii, 875-1036.

This special issue highlights areas in otolaryngology where simulation is being used to develop multidisciplinary team-based approaches to care and education. Topics covered include the use of simulation for system improvement, the value of debriefing, and the economics of simulation.
Kearney JA, Deutsch ES. Otolaryngol Clin North Am. 2017;50:1015-1028.
Simulations in health care can help uncover technical weaknesses, teamwork gaps, and system problems. This review explores simulation use in otolaryngology and outlines key components of in-situ simulation and how to perform one.
Danino J, Muzaffar J, Metcalfe C, et al. Eur Arch Otorhinolaryngol. 2017;274:1317-1326.
This review discusses general patient safety concerns and those specific to otolaryngology, including problems related to use of lasers, diagnostic discrepancies associated with thyroid conditions, risks linked to use of adrenaline in the surgical field, and incidents involving wrong-site surgery.
Ahmed A, Ahmad M, Stewart M, et al. Laryngoscope. 2015;125:837-41.
This direct observation study revealed that surgeons performed with less dexterity and made more errors when distractions were present in the operating room compared to when no distraction occurred, and this effect was more pronounced in those with less experience. Consistent with prior work on interruptions and distractions, this finding underscores the need to augment health care work environments to improve safety.
Geyton T, Odutoye T, Mathew R. Am J Rhinol Allergy. 2014;28:219-23.
This study examined the characteristics of medical negligence claims in otolaryngology (ear, nose, and throat) cases in the United Kingdom. Researchers reviewed 65 closed cases that resulted in payouts and found that surgical complications were implicated in 50 of the cases. The most common complaint was failure to recognize or appropriately manage complications.
McCormick ME, Stadler ME, Shah RK. Otolaryngol Head Neck Surg. 2015;152:778-782.
This commentary explores the unique challenges involved in integrating core principles of safety and quality improvement into otolaryngology–head and neck surgery education and describes strategies to address them. The authors draw from the experience of other specialty-focused medical education efforts to suggest topics to cover, effective ways to deliver content, and morbidity and mortality conferences as elements of successful programs.
Lord T. Patient Saf Qual Healthc. March/April 2012;9:38-41,44.
This article details how miscommunication and lack of patient-centered care contributed to errors that led to the death of a child.
Mathew R, Asimacopoulos E, Valentine P. Laryngoscope. 2011;121:2214-9.
This study found that operative complications were the most common source of medical negligence claims in otology. While claims were associated with a high rate of success in settlement, a significant proportion of the issues were nonsurgical and offer an opportunity for prevention strategies.