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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 1728 Results
Larsson F, Strömbäck U, Rysst Gustafsson S, et al. Int J Qual Stud Health Well-being. 2023;18:2216018.
Patients expect to "feel safe" in healthcare settings. This concept analysis describes defining attributes (participation, control, presence) of patients in the perioperative environment. Through a series of cases that include all, some, or none of the safety attributes, the authors illustrate the concept of patients "feeling safe" in the perioperative environment.
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%).

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.
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
Ambulatory surgery centers (ASCs) are increasingly being used to provide surgical care. The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center Survey seeks opinions from the field regarding safety culture in the ambulatory surgical center environment. The survey is presented with additional resources to help organizations assess their safety culture, including the results of a pilot program testing the survey and a user's guide. Voluntary data submission will be open June 1-22 for ASCs that have administered the survey.
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.
Fillo KT, Saunders K. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2023.
This reoccurring report compiles patient safety data collected by Massachusetts hospitals. The 2022 numbers document an increase in serious reportable events recorded in acute care hospitals, from 1430 the previous year to 1632. This presentation also includes events from ambulatory surgery centers. Older reports are also available.
Arad D, Rosenfeld A, Magnezi R. Patient Saf Surg. 2023;17:6.
Surgical never events are rare but devastating for patients. Using machine learning, this study identified 24 contributing factors to two types of surgical never events - wrong site surgery and retained items. Communication, the number and type of staff present, and the type and length of surgery were identified contributing factors.

ACS TQIP Mortality Reporting System Writing Group. J Trauma Acute Care Surg. 2023.

Anonymous case reporting provides opportunities to examine unexpected patient harm instances to pinpoint process changes and enhance learning. This case series shares analysis of adverse events submitted to a trauma center-focused reporting program as tools for improvement. The cases are freely available.
May 4, 2023
The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.
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.
Anesthesia Patient Safety Foundation. September 6–7, 2023; Red Rock Casino Resort and Spa, Las Vegas, NV.
Anesthesia is a high-risk activity that has achieved safety successes. This hybrid conference will explore topics related to the theme of “Emerging Medical Technologies – A Patient Safety Perspective on Wearables, Big Data and Remote Care.”
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.

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.
Richburg CE, Dossett LA, Hughes TM. Surg Clin North Am. 2023;103:271-285.
Cognitive biases can threaten patient safety in a variety of ways. This narrative review summarizes the common cognitive biases in surgical care and how they threaten patient safety, including delays in diagnosis and treatment, unnecessary surgeries, and intraoperative errors and complications. The authors also discuss cognitive debiasing strategies to mitigate the impact of cognitive biases.
Duffy C, Menon N, Horak D, et al. JAMA Netw Open. 2023;6:e237621.
Safety-II is a proactive approach to improving patient safety by focusing on what goes right in healthcare. This study describes the use of a novel tool and activity, One Safe Act (OSA), to capture activities performed by perioperative staff that keep patients safe. Eight themes emerged, with the most common theme being routines the staff “always” performed, followed by confirming resource availability.
Patient Safety Surveillance Unit. Department of Health, Perth: Western Australia.
This annual report shares the results of Western Australia's sentinel event reporting program. Medication errors were the highest recorded sentinel event in the latest period. The data is placed in the context of the overall data collected over the last 5 years of the program.
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.
Quan SF, Landrigan CP, Barger LK, et al. J Clin Sleep Med. 2023;19:673-683.
Fatigue and sleep deprivation among healthcare workers can increase the risk of errors. This prospective study including 60 attending surgeons from departments of surgery or obstetrics and gynecology at eight hospitals found that sleep deficiency was not associated with greater numbers of errors during procedures performed the next day. However, non-technical skill performance, situational awareness, and decision making were adversely associated with sleep deficiency.  
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.