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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 - 16 of 16 Results

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.
WebM&M Case November 16, 2022

A 61-year-old women with a mechanical aortic valve on chronic warfarin therapy was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. CT imaging revealed two arterial thromboses the right lower extremity and an echocardiogram revealed a thrombus near the prosthetic heart valve. The attending physician ordered discontinuation of warfarin and initiation of a heparin drip.

WebM&M Case August 31, 2022

A 49-year-old woman was referred by per primary care physician (PCP) to a gastroenterologist for recurrent bouts of abdominal pain, occasional vomiting, and diarrhea. Colonoscopy, esophagogastroduodenoscopy, and x-rays were interpreted as normal, and the patient was reassured that her symptoms should abate. The patient was seen by her PCP and visited the Emergency Department (ED) several times over the next six months. At each ED visit, the patient’s labs were normal and no imaging was performed.

Bhatt AS, Moscone A, McElrath EE, et al. J Am Coll Cardiol. 2020;76:280-288.
Patients are delaying or forgoing necessary care due to concerns about COVID-19 transmission. This study analyzed inpatient discharges between January 2019 and March 2020 at one tertiary healthcare system to explore the trends in hospitalizations for acute cardiovascular conditions (e.g., chest pain, heart failure, stroke) before and during the COVID-19 pandemic. Results showed that during the early months of the pandemic, there was a marked decline in hospitalizations for acute cardiovascular conditions and patients who were admitted had shorter lengths of stay, which may signal that acute care was deferred or abbreviated during the pandemic.
WebM&M Case November 27, 2019
Three patients were at the same hospital over the course of a few months for vascular access device (VAD) placement and experienced adverse outcomes. The adverse outcomes of two of them were secondary to drugs given for sedation, while the third patient’s situation was somewhat different. Vascular access procedures are extremely common and are relatively short but may require the use of procedural sedation, which is usually very well tolerated but can involve significant risk, as these cases illustrate.
Collins SA, Couture B, Smith A, et al. J Patient Saf. 2020;16:e75-e81.
Detecting adverse events in the health care setting remains an ongoing challenge. Engaging patients and their family members may help to escalate safety issues not identified by other means. In this mixed-methods study, investigators analyzed the types of issues patients and their care partners reported in real time through a web-based electronic application implemented on three hospital units. After implementation of the tool, event reporting by patients to the Patient Family Relations Department declined, suggesting that patients preferred to report concerns anonymously through the application. The authors conclude that additional research is needed to understand how these types of applications could be integrated into patient safety programs. A past PSNet perspective highlighted how patient-facing technologies can empower patients.
Rose J, Evans C, Barleben A, et al. JAMA Surg. 2014;149:926-32.
Using AHRQ Patient Safety Indicators to compare two surgical techniques for abdominal aortic aneurysm repair, this chart review study found that endovascular repair was safer, emphasizing the utility of these measures for characterizing surgical safety despite controversy about their accuracy.
Hernandez-Boussard T, McDonald KM, Morton J, et al. J Am Coll Surg. 2012;214:788-97.
Vascular surgery is considered a higher risk surgical specialty, as many patients undergoing vascular procedures are elderly and have other comorbid illnesses, putting them at elevated risk of postoperative complications. This study used Patient Safety Indicators (PSIs) to analyze more than 1.4 million patients who underwent vascular surgery from 2005–2009 and found that more than 5% experienced a postoperative adverse event. Procedural complexity and comorbidities were associated with increased risk of a PSI, corroborating prior studies that have found a link between illness severity and risk of complications in medical patients. The PSIs are best used to screen administrative data for potential adverse events, as in this study. In surgical patients, the National Surgical Quality Improvement Program measures have been shown to be superior for accurate detection of postoperative adverse events.
Catchpole K, Dale TJ, Hirst G, et al. J Patient Saf. 2010;6:180-6.
This study found that a teamwork training program increased compliance with time outs, briefings, and debriefings in multiple surgical settings. Based on noted interactions between NOTECHS scores and individual sites, the authors advocate for greater attention to elements of safety culture such as organizational commitment.
Volpp KG, Rosen AK, Rosenbaum PR, et al. J Gen Intern Med. 2009;24:1149-55.
The safety impact of the ACGME trainee work hour restrictions remains controversial due to contrasting findings that have suggested benefit, harm, and no significant impact. This observational study analyzed all Medicare patients admitted to acute care facilities with a predefined set of primary diagnoses to estimate the 30-day mortality among high-severity medical admissions and the failure to rescue in postoperative surgical admissions. Investigators found no significant harm or benefit to patients with higher-severity illness compared with those with lower risk among both the medical and surgical patients. A past AHRQ WebM&M perspective discussed the impact of fatigue and extended shifts among trainees on the incidence of medical errors.
WebM&M Case October 1, 2009
Following surgery for peripheral vascular disease, a patient otherwise ready for discharge complains of liquid shooting from his nose. The surgeons make the patient NPO and order a consultation from an otolaryngologist, who discovers the nasopharyngeal airway still lodged in the patient's nasal cavity.
Khuri SF, Henderson WG, Daley J, et al. Ann Surg. 2008;248:329-36.
The Patient Safety in Surgery study documented remarkable improvements in postoperative outcomes at Veterans Affairs hospitals following implementation of a quality improvement program. This study demonstrated similar improvement in clinical outcomes, including surgical site infection rates, following implementation of the program in private sector hospitals.