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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 - 10 of 10 Results
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.

Arnaoutakis GJ, Ogami T, Aranda‐Michel E, et al. J Am Heart Assoc. 2022;11:e025026.
Missed diagnosis of aortic emergencies can result in patient death, therefore patients with presumed aortic syndromes may be transferred to aortic referral centers. Because interhospital transfers present their own risks, these researchers evaluated emergency transfers of patients who did not ultimately have a diagnosis of acute aortic dissection, intramural hematoma, penetrating aortic ulcer, thoracic aortic aneurysm, or aortic pseudoaneurysm. Approximately 11% of emergency transfers were misdiagnosed, secondary to imaging misinterpretation.

Gabler E. New York Times. May 31, 2019.

Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.
Hernandez-Boussard T, Downey JR, McDonald KM, et al. Health Serv Res. 2011;47.
Studying the relationship between hospital volume, surgical volume, and clinical outcomes, past research in part led to recommendations for volume-based referral as a safety practice. However, the volume–outcome relationship may be limited to selected surgical procedures, suggesting that systematic volume-based referral is unnecessary. This study further examines these relationships by evaluating the impact of hospital surgical volume on preventable adverse events. The latter were measured using the AHRQ Patient Safety Indicators (PSIs), which have noted limitations as measures of safety. Nevertheless, investigators found that hospital volume for abdominal aortic aneurysm, coronary bypass graft, and Roux-en-Y gastric bypass were inversely related to PSI rates. Additional research to further evaluate the structural and process differences between outcomes and hospital volume may help identify potential safety solutions.
Jha AK, Orav J, Ridgway AB, et al. Jt Comm J Qual Patient Saf. 2008;34:318-325.
The Leapfrog Group is a consortium of private and public employers who collectively purchase health care for more than 30 million Americans. Leapfrog recommends four evidence-based practices for implementation by hospitals: computerized provider order entry, intensivist coverage of critically ill patients, evidence-based hospital referral for high-risk patients, and adoption of the National Quality Forum's safe practices. This study found that hospitals that reported implementing at least one patient safety practice also provided slightly better care for myocardial infarction and congestive heart failure (as measured by publicly reported quality data), but not for pneumonia. The authors note that as the Leapfrog recommended practices are not directly tied to improving care quality for these specific conditions, implementation of Leapfrog patient safety practices likely indicates an overall commitment to providing higher-quality care.
Shojania KG, Burton EC. N Engl J Med. 2008;358:873-5.
Autopsies are rarely performed, despite a wealth of literature demonstrating that diagnostic errors are still frequently detected postmortem. The authors discuss the implications of this problem and potential solutions, including the establishment of regional high-volume autopsy centers.
Luft HS, Bunker JP, Enthoven AC. N Engl J Med. 1979;301:1364-9.
This study evaluated nearly 1500 hospitals to determine the relationship between their mortality rates and surgical volume for 12 selected procedures. Results include detailed tables of data and illustrative graphs for each procedure, suggesting a number of clear trends. Mortality associated with open-heart surgery, vascular surgery, transurethral resection of the prostate, and coronary bypass decreased with increasing volume at a given hospital. For other procedures, the mortality curve flattened at lower volumes, and some showed no relationship between volume and mortality. Although the authors recommend caution in interpretation and provide explanations for findings, they conclude that regionalization should warrant consideration for certain procedures.
WebM&M Case January 1, 2004
A triage nurse instructed by a physician to immediately bring a febrile child, who was possibly dehydrated, to the treatment area is stopped by the charge nurse, citing overcrowding. The parents seek treatment elsewhere; upon arrival, the child is in full arrest.