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 244 Results

Use of technology to improve the adherence to surgical safety checklists in the operating room.

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Pati AB, Mishra TS, Chappity P, et al. Jt Comm J Qual Patient Saf. 2023;Epub Apr 22.

The World Health Organization (WHO) Surgical Safety Checklist is widely used, but implementation challenges remain. This article describes the development of an electronic version of the surgical safety checklist adapted for use on a personal device, and compared its use against the traditional paper-based checklist. The electronic checklist had 100% use (compared to 98% for the traditional checklist) and significantly higher frequency of completion (100% vs. 27%).

SOPS Ambulatory Surgery Center Survey: What You Need to Know.

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Agency for Healthcare Policy and Research: April 27, 2023.

Ambulatory surgery centers (ASC) experience a variety of error types that can be acerbated by poor safety culture. This webcast provided information on AHRQ’s Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center (ASC) Survey, including a review of the SOPS ASC program, survey administration, database submission, and available resources.

Patient safety trends in 2022: an analysis of 256,679 serious events and incidents from the nation’s largest event reporting database.

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Kepner S, Jones RM. Patient Saf. 2023;Epub Apr 28.

Pennsylvania requires all acute care facilities to report incidents and serious events to the Pennsylvania Patient Safety Reporting System (PA-PSRS). This report compiles reports submitted in 2022 and compares results to previous years. There was a decrease in the total number of reports submitted, but serious and high harm events increased. The most frequently reported event continues to be Error Related to Procedure/Treatment/Test followed by Complication of Procedure/Treatment/Test, Medication Error, and Fall.

Impact of the percentage of overlapping surgery on patient outcomes: a retrospective cohort study of 87,000 surgical cases.

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Pitts CC, Ponce BA, Arguello AM, et al. Ann Surg. 2023;277:756-760.

Overlapping surgery – when surgeons schedule distinct procedures on different patients concurrently – has raised safety concerns but recent studies have not found significant differences in perioperative outcomes. This retrospective cohort study including over 87,000 surgical cases found that overlapping surgeries increased operative times but did not lead to increased in-hospital mortality, adverse events, or readmission rates when compared to nonoverlapping cases.

Patient Safety Authority Annual Reports.

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Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2023.

This report summarizes patient safety improvement work in the state of Pennsylvania. It reviews the 2022 activities of the Patient Safety Authority that reflected a strategic emphasis on reporting compliance and data quality. Additional sections cover educational, publication, and learning management system efforts.

The high cost of retained surgical items.

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Moorehead LD. Outpatient Surgery. April 5, 2023.

Retained surgical items (RSIs) are considered “never events” but continue to be a source of patient harm. This article discusses the various factors that increase risk of RSIs and strategies to prevent them, such as a consistent counting process and fostering a culture of safety that encourages speaking up and a non-punitive response to errors.

Development and interrater agreement of a novel classification system combining medical and surgical adverse event reporting.

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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.

A standardized marking procedure for ENT operations to prevent wrong-site surgery: development, establishment and subsequent evaluation among patients and medical personnel.

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Patient Safety Innovation March 29, 2023

Although wrong-site surgeries are rare, they can be devastating to patients. One otolaryngology (ENT) clinic developed a surgical marking procedure deemed practicable and useful by both providers and patients.

A novel approach for engagement in team training in high-technology surgery: the robotic-assisted surgery olympics.

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Patient Safety Innovation March 29, 2023

Improving non-technical skills - such as teamwork and communication – is essential to safe delivery of healthcare but implementing successful training programs has been challenging.

Understanding patient and clinician reported nonroutine events in ambulatory surgery.

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Salwei ME, Anders S, Slagle JM, et al. J Patient Saf. 2023;19:e38-e45.

Understanding deviations in care can identify opportunities to improve care delivery and patient safety. This study assessed the incidence and nature of patient- and clinician-reported deviations from optimal care (“non-routine events” or NRE) during ambulatory surgery. The most common type of clinician-reported NRE was process deficiencies, while failures in communication between clinicians and patients or family members was the most common type of patient-reported NRE. Understanding patient perspectives on care deviations can identify opportunities for process improvements and more patient-centered care.

Prevention of perioperative medication errors.

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Nanji K. UpToDate. March 17, 2023.

Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical setting and discusses prevention strategies that focus on medication reconciliation, technology, standardization, and institutional change.

Distraction of the Anesthesiologist and Lack of Resuscitation Drugs Resulting in Delayed Treatment of Laryngospasm.

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WebM&M Case March 15, 2023

A 48-year-old woman was placed under general anesthesia with a laryngeal mask. The anesthesiologist was distracted briefly to sign for opioid drugs in a register, and during this time, the end-tidal carbon dioxide alarm sounded. Attempts to manually ventilate the patient were unsuccessful. The anesthesiologist asked for suxamethonium (succinylcholine) but the drug refrigerator was broken and the medication had to be retrieved from another room.

Medication Handling and Compounding Errors in the Operating Room.

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WebM&M Case March 15, 2023

This case focuses on immediate-use medication compounding in the operating room and how the process creates situations in which medication errors can occur. The commentary discusses strategies for safe perioperative compounding and the role of standardized processes, such as checklists, to ensure medication safety.

Automated capture of intraoperative adverse events using artificial intelligence: a systematic review and meta-analysis.

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Eppler MB, Sayegh AS, Maas M, et al. J Clin Med. 2023;12:1687.

Real-time use of artificial intelligence in the operating room allows surgeons to avoid or immediately address intraoperative adverse events. This review summarizes 13 articles published since 2010 that report on the use of artificial intelligence to predict intraoperative adverse events. Most studies used video and more than half were intended to detect bleeding.

Communication matters when it comes to adverse events: associations of adverse events during implant treatment with patients' communication quality and trust assessments.

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Schrimpff C, Link E, Fisse T, et al. Patient Educ Couns. 2023;110:107675.

Trust between patients and providers is essential to safe, effective healthcare. This survey of German patients undergoing implant surgeries (e.g., hip and knee replacements, dental implants, cochlear implants) found that adverse events negatively impact patient trust in their physicians, but effective patient-provider communication can mitigate the impacts.

Surgical fire in the United States: 2000-2020.

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Grauer JS, Kana LA, Alzouhayli SJ, et al. Surgery. 2022;173:357-364.

Surgical fires, while rare, can result in the injury, permanent disability, or death of patients or healthcare workers. Between 2000 and 2020, 565 surgical fires resulting in injury were reported to the FDA’s Manufacturer and User Facility Device Experience (MAUDE) database. Fires were most likely to occur during upper aerodigestive tract and head and neck surgeries; these were also most likely to result in life-threatening injury.

Managing safety in perioperative settings: strategies of meso-level nurse leaders.

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Brooks JV, Nelson-Brantley H. Health Care Manage Rev. 2023;48:175-184.

Effective nurse managers support a culture of safety and improved patient outcomes. This study explores strategies implemented by meso-level nurse leaders - nurse managers between executive leadership and direct care nurses – to enable a culture of safety in perioperative settings. Four strategies were identified: (a) recognizing the unique perioperative management environment, (b) learning not to take interactions personally, (c) developing "super meso-level nurse leader" skills, and (d) appealing to policies and patient safety.

Evaluation of policies limiting opioid exposure on opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large American health system.

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Rennert L, Howard KA, Walker KB, et al. J Patient Saf. 2023;19:71-78.

High-risk opioid prescribing can increase the risk of abuse and overdose. This study evaluated the impact of four opioid prescribing policies for opioid-naïve patients – nonopioid medications during surgery, decreased opioid doses in operating rooms, standardized electronic health record alerts, and limits on postoperative opioid supply – implemented by one opioid stewardship program in a large US healthcare system between 2016 and 2018. Post-implementation, researchers observed decreases in postoperative opioid prescription doses, fewer opioid prescription refills, and less patient-reported discharge pain.

Compliance with and barriers to implementing the surgical safety checklist: a mixed-methods study.

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Aydin Akbuga G, Sürme Y, Esenkaya D. AORN J. 2023;117:e1-e10.

The World Health Organization’s Surgical Safety Checklist has been used in populations around the globe to reduce surgical complications and improve operating room teamwork. This mixed methods study involved nearly 150 surgical nurses in Turkey. Nurses reported inconsistent use of the checklist, described barriers to its use, and offered suggestions to increase compliance with completion.

Cognitive biases in surgery: systematic review.

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Armstrong BA, Dutescu IA, Tung A, et al. Br J Surg. 2023;110:645-654.

Cognitive biases are a known source of misdiagnosis and post-operative complications. This review sought to identify the impact of cognitive biases on surgical performance and patient outcomes. Through thematic analysis of 39 studies, the authors identified 31 types of cognitive bias across six themes. Importantly, none of the included studies investigated the source of cognitive bias or mitigation strategies.

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