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.
Jewell ML, Jewell HL, Singer R, et al. Aesthetic Plast Surg. 2023;Epub Mar 28.
Fentanyl is a high-risk medication, whether prescribed by a health professional or obtained illicitly. This patient safety advisory encourages healthcare providers to educate their patients on the risks of counterfeit fentanyl.
Khansa I, Pearson GD. Plast Reconstr Surg Glob Open. 2022;10:e4203.
Some clinicians experience profound emotional distress following an adverse event, known as the “second victim” phenomenon. This study of surgical residents in the US found that most residents who reported being part of a medical error had subsequent emotional distress, including guilt, anxiety, and insomnia. Importantly, while three quarters of residents reported they did not get emotional support following the event, all those who did get support reported benefiting from it.
Fan B, Pardo J, Yu-Moe CW, et al. Ann Surg Oncol. 2021;28:8109-8115.
While prior research has described malpractice cases related to breast cancer diagnosis and treatment, this study sought to identify errors specifically related to breast cancer surgical procedures. Plastic surgeons were the most commonly named provider type (64%), error in surgical treatment was the most common allegation (87%), and infection, cosmetic injury, emotional trauma, foreign body, and nosocomial infection were the top 5 injury descriptions.
Best JA, Kim S. J Contin Educ Nurs. 2019;50:355-361.
A key aspect of a robust safety culture is that all team members feel psychologically safe in difficult situations. This commentary describes the development and use of a speaking-up curriculum that focuses on communication skills, cultural expectations, cognitive restructuring techniques, and resilience strategies. The program successfully increased motivation and comfort of participants in sharing concerns in various clinical situations.
Wrong-patient and wrong-site surgeries are considered never events. This commentary describes a tool developed to decrease confusion in plastic surgery. The authors envision the tool to enhance team communication and preparation, which should reduce risk of wrong-site surgery.
Human factors perspectives can inform design and implementation of safety interventions in health care. This commentary summarizes the role of human factors engineering and checklists as safety improvement strategies in plastic surgery. The authors highlight nontechnical skill development, checklist customization, raising of concerns, and safety assessment as key areas of focus for the specialty.
Nijhawan RI, Lee EH, Nehal KS. Dermatol Surg. 2015;41:499-504.
This study found that encouraging patients to take skin biopsy selfies on smartphones may help patients and physicians more accurately identify the correct biopsy site for subsequent surgical excision, potentially avoiding wrong-site surgeries.
Biskup N, Workman AD, Kutzner E, et al. Ann Plast Surg. 2016;76:550-5.
Implementation of the World Health Organization surgical safety checklist did not affect complication rates among plastic surgery patients at an academic medical center. Other studies have found similar disappointing results, the implications of which are discussed in a recent AHRQ WebM&M interview.
Vercler CJ, Buchman SR, Chung KC. Ann Plast Surg. 2015;74:140-144.
Disclosure and apology programs are recognized as elements of an effective organizational response to medical error. Using a case study involving an iatrogenic burn injury and disclosure, this review relates how three ethical principles apply to error disclosure.
Hernandez-Boussard T, McDonald KM, Rhoads KF, et al. Ann Plast Surg. 2015;74:597-602.
Using AHRQ patient safety indicators, this study established that approximately 4% of plastic surgery patients experience an adverse event during their hospital stay. This rate is relatively low compared with other surgical disciplines, but it is significant due to the proportion of young healthy patients who undergo plastic surgery.
Patel SP, Gauger PG, Brown DL, et al. J Am Coll Surg. 2010;211:540-5.
Do resident physicians contribute disproportionately to medical errors? The evidence is mixed, despite the longstanding concern about a purported increase in errors in July, when most new residents start their training. This study compared complication rates in breast reduction surgery between surgical residents and an attending physician, and found no evidence of increased complications in procedures performed primarily by residents with close attending supervision. However, poor supervision of residents has resulted in substandard care in other settings.
Four months after surgery, a woman with osteosarcoma receiving outpatient chemotherapy was admitted for possible cellulitis. Discharged home on methotrexate and antibiotics, the patient developed methotrexate toxicity, partly due to a drug interaction.
Coldiron BM, Healy C, Bene NI. Dermatol Surg. 2008;34:285-91; discussion 291-2.
Patient safety in ambulatory surgery centers (ASCs) has received increasing attention, and the Joint Commission's National Patient Safety Goals now include specific requirements for ASCs. This study summarizes the types and severity of adverse events occurring in ASCs in Florida, gathered using that state's mandatory reporting system. The majority of deaths and hospital transfers occurred in patients undergoing cosmetic procedures, incidents that are generally considered never events. A previous AHRQ WebM&M commentary and perspective discuss the issues pertaining to improving safety in outpatient surgery, which remains a largely unregulated area.
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