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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 226 Results
Tan GM, Murto K, Downey LA, et al. Paediatr Anaesth. 2023;33:609-619.
Blood management errors can lead to serious patient harm. This article highlights five patient safety risks during pediatric perioperative blood management (failure to recognize and treat preoperative anemia, failure to obtain informed consent regarding perioperative blood management, failure to consider specific intraoperative blood conservation techniques in children, failure to recognize massive hemorrhage, failure to prevent unnecessary transfusion). The authors discuss potential solutions to address these safety risks.
Baimas-George MR, Ross SW, Yang H, et al. Ann Surg. 2023;278:e614-e619.
Hospital-acquired venous thromboembolism (VTE) remains a significant source of preventable patient harm. This study of 4,252 high-risk general surgery patients found that only one-third received care in compliance with VTE prophylaxis guidelines. Patients receiving guideline-compliant care experienced shorter lengths of stay (LOS), fewer blood transfusions, and decreased odds of having a VTE, emphasizing the importance of initiating VTE chemoprophylaxis in high-risk general surgery patients.

Waldman A. ProPublica. August 9, 2023

Systemic failures can enable poor practice to perpetuate without regard to safety. This news feature reports on systemic flaws that enabled a vascular surgeon with questionable business and clinical skills to continue to practice after numerous regulatory organizations investigated his clinics, and after patients reported harm.
Rabbani N, Pageler NM, Hoffman JM, et al. Appl Clin Inform. 2023;14:521-527.
Implementation of or upgrades to new electronic health records (EHR) is a complex process which sometimes results in unforeseen negative consequences. This study examines hospital-acquired conditions (HACs) and care bundle compliance rates at 27 pediatric hospitals before, during, and after implementation or upgrade of EHR systems. Contrary to previous studies, no significant differences were found in either HAC or bundle compliance rates.
Rosa R, Sposato K, Abbo LM. AORN J. 2023;117:300-311.
Preventing surgical site infections remains a persistent challenge to patient safety. This article outlines strategies to prevent surgical site infections during the perioperative period and the roles that infection surveillance, infection prevention bundles, and a culture of safety play a substantial role in decreasing the rate of surgical site infections.
Birkeli GH, Ballangrud R, Jacobsen HK, et al. BMJ Open Qual. 2023;12:e002247.
Interprofessional huddles and voluntary reporting of incidents and near-misses are ways to improve patient safety and safety culture. This Norwegian post-anesthesia care unit (PACU) implemented a voluntary incident reporting method, Green Cross (GC), that includes daily team huddles to discuss reports from the previous 24 hours. Three years after implementation, staff reported GC was still active, but use has declined, particularly during the COVID-19 pandemic. They also reported a desire for increased follow up and physician involvement.
Vaughan-Malloy AM, Chan Yuen J, Sandora TJ. Am J Infect Control. 2023;51:514-519.
Hand hygiene adherence is an essential component of patient safety. Using the SEIPS 2.0 model, this study explored clinician perspectives about high reliability in hand hygiene. The 61 respondents identified several barriers associated with aspects of organizational culture, environment, tasks and tools, including frequently empty alcohol-based hand rub dispensers and challenges with the layout of patient care areas.
Pfeiffer Y, Atkinson A, Maag J, et al. J Patient Saf. 2023;19:264-270.
Surgical site infections (SSI) are a common, but preventable, complication following surgery. This study sought to determine the association of commitment to, knowledge of, and social norms surrounding SSI prevention efforts and safety climate strength and level. Based on responses from nearly 2,800 operating room personnel in Sweden, only commitment and social norms were associated with safety climate level. None were associated with safety climate strength.
Duffy C, Menon N, Horak D, et al. J Patient Saf. 2023;19:281-286.
Resiliency and proactive safety behaviors can improve safety in the perioperative environment. In this article, the authors describe safety attitudes of perioperative staff after participating in a proactive activity, One Safe Act (OSA). Most participants reported the OSA activity would change their work practices, improve their work unit's ability to deliver safe care, and demonstrate their colleagues' commitment to patient safety.
King CR, Shambe A, Abraham J. JAMIA Open. 2023;6:ooaf015.
Handoffs and transitions of care represent a vulnerable time for patients as important information must be shared and understood by multiple people. This study focuses on postoperative nurse handoffs, specifically regarding situational awareness and anticipatory guidance, and the role artificial intelligence (AI) could play in improving handoffs. Five themes were uncovered, including the importance of situational awareness and associated barriers, how AI could address those barriers, and how AI could result in new/additional barriers.
WebM&M Case March 29, 2023

This patient with recently diagnosed adenocarcinoma of the esophagus underwent esophagoscopy with endoscopic ultrasound, which was complicated by thoracic esophageal perforation. The perforation was endoscopically closed during the procedure. However, there was a lack of clear communication regarding the operator’s confidence in the success of endoscopic closure and their recommendations for the modality and timing of follow-up imaging, which ultimately led to significant delays in patient care.

Namiranian, MD, PhD K. J Opioid Manag. 2023;19:69-76.
Prescription opioids are commonly used to manage surgical and non-surgical pain but misuse of opioids is a serious patient safety concern. In this retrospective cohort study of Veterans Health Administration patients, researchers found that opioid misuse among previously opioid-naïve patients increases significantly after 11 months of chronic use, regardless of whether the opioid was prescribed for surgical or non-surgical pain.
Seidelman JL, Mantyh CR, Anderson DJ. JAMA. 2023;329:244-252.
Surgical site infections (SSIs) remain a significant cause of preventable post-operative morbidity and mortality. This narrative review summarizes modifiable and nonmodifiable patient-related factors. It also evaluates modifiable operation-related factors associated with surgical site infections, and highlights six pre-, intra-, and postoperative strategies to reduce surgical site infections, including use of the WHO surgical safety checklist.
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.

Sutton E, Booth L, Ibrahim M, et al. Qual Health Res. 2022;32:2078-2089.
Patient engagement and encouragement to speak up about their care can promote patient safety. This qualitative study explored patients’ psychosocial experiences after surviving abdominal surgery complications. Findings highlight an overarching theme of vulnerability and how power imbalances between patients and healthcare professionals can influence speaking up behaviors.
Varady NH, Worsham CM, Chen AF, et al. Proc Natl Acad Sci USA. 2022;119:e2210226119.
Safe prescribing dictates that prescriptions should only be written for the patients who are intended to use the prescribed medications. Using claims data, this analysis identified a high rate of opioid prescriptions written for and filled by the spouses of patients undergoing outpatient surgery (who may be unable to fill prescriptions themselves after surgery). Findings suggest intentional, clinically inappropriate prescribing of opioids.
Wani MM, Gilbert JHV, Mohammed CA, et al. J Patient Saf. 2022;18:e1150-e1159.
The WHO surgical safety checklist has been implemented in healthcare systems around the world. This scoping review identified five categories of barriers to successful implementation of the WHO checklist (organizational-, checklist-, technical-, and implementation barriers, as well as individual differences). The authors outline recommendations for researchers, hospital administrators, and operating room personnel to improve checklist implementation.  
Marsh KM, Turrentine FE, Schenk WG, et al. Ann Surg. 2022;276:e347-e352.
The perioperative period represents a vulnerable time for patients. This retrospective review of patients undergoing surgery at one hospital over a one-year period concluded that medical errors (including, but not limited to, technical errors, diagnostic errors, system errors, and errors of omission) were strongly associated with postoperative morbidity.
WebM&M Case December 14, 2022

A 62-year-old Spanish-speaking woman presented to the pre-anesthesia area for elective removal of a left thigh lipoma. Expecting a relatively simple outpatient operation, the anesthesiologist opted not to use a Spanish language translator and performed a quick pre-anesthesia evaluation, obtaining her history from the medical record. Unknown to the anesthesiologist, the patient was trying to communicate to him that she had undergone jaw replacement surgery and that her mouth opening was therefore anatomically limited.

WebM&M Case October 27, 2022

A 47-year-old man underwent a navigational bronchoscopy with transbronchial biospy under general anesthesia without complications. The patient was transferred to the post-acute care unit (PACU) for observation and a routine post-procedure chest x-ray (CXR). After the CXR was taken, the attending physician spoke to the patient and discussed his impressions, although he had not yet seen the CXR. He left the PACU without communicating with the bedside nurse, who was caring for other patients. The patient informed the nurse that the attending physician had no concerns.