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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 24 Results
Jt Comm J Qual Patient Saf. 2023;Epub Oct 18.
Surgical fires are a rare yet potentially harmful event for both patients and care teams. The alert provides reduction guidance for organizations to mitigate conditions that enable surgical fires and suggests tactics to improve communication as a primary strategy for preventing this potentially catastrophic accident in operating rooms.
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.
Oppikofer C, Schwappach DLB. Plast Reconstr Surg. 2017;140:812e-817e.
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.
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.
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.
Trussler AP, Tabbal GN. Plast Reconstr Surg. 2013;130:470e-478e.
This commentary outlines tactics to prevent complications in plastic surgery, including electronic medical records implementation and incident reporting.
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.
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.