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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 132 Results
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.
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.
Joint Commission.
This website provides sentinel event data reported to The Joint Commission, which includes information on sentinel events reported from January through December 2022. Falls, unintended retained foreign bodies, and delays in treatment were among the most frequently submitted incidents in this time period which represents a 19% increase over 2021. The data and graphs are updated regularly and include a 5 year trend analysis and specific analysis associated with event type by year from 2018 through 2022.
Tan J, Ross JM, Wright D, et al. Jt Comm J Qual Patient Saf. 2023;49:265-273.
Wrong-site surgery is considered a never event and can lead to serious patient harm. This analysis of closed medical malpractice claims on wrong-site surgery between 2013 and 2020 concluded that the risk of wrong-site surgery increases with spinal surgeries (e.g., spinal fusion, excision of intervertebral discs). The primary contributing factors to wrong-site surgery was failure to follow policy or protocols (such as failure to follow the Universal Protocol) and failure to review medical records.
Vacheron C-H, Acker A, Autran M, et al. J Patient Saf. 2023;19:e13-e17.
Wrong-site, wrong-procedure, and wrong-patient errors (WSPEs) are serious adverse events. This retrospective analysis of medical liability claims data examined the incidence of WSPEs in France between 2007 and 2017. During this ten-year period, WSPEs accounted for 0.4% of all claims. Procedures on the wrong organ were most common (44%), followed by wrong side (39%), wrong person (13%) and wrong procedure (4%). The researchers found that the average number of WSPEs decreased after implementation of a surgical checklist.

Otolaryngol Head Neck Surg. 2018-2023.

Otolaryngology-head and neck surgery is vulnerable to wrong site errors and other challenges present in surgical care. This series of articles highlights key areas of importance for the specialty as they work to enhance patient safety. The latest 2023 installment covers psychological safety.
St Paul, MN: Minnesota Department of Health.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.
Minyé HM, Benjamin EM. Br Dent J. 2022;232:879-885.
High reliability organization (HRO) principles used in other high-risk industries (such as aviation) can be applied patient safety. This article provides an overview of how HRO principles (preoccupation with failure, situational awareness, reluctance to simplify, deference to expertise, and commitment to resilience) can be successfully applied in dentistry.
Krenzischek DA, Card E, Mamaril M, et al. J Perianesth Nurs. 2022;37:827-833.
Patients and caregivers are important partners in promoting safe care. Findings from this cross-sectional study reinforce the importance of patients’ perceived roles in ensuring safe surgery and highlight the importance of patient engagement in mitigating surgical site errors.

Farnborough, UK: Healthcare Safety Investigation Branch; June 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.

Farnborough, UK: Healthcare Safety Investigation Branch; April 2021.

Wrong-site surgery in dentistry is a frequent and persistent never event. This report examines a case of pediatric wrong tooth extraction to reveal how the application of safety standards is influenced by the work environment and discusses the use of forcing functions to create barriers to error in practice.
Olivarius‐McAllister J, Pandit M, Sykes A, et al. Anaesthesia. 2021;76:1616-1624.
UK Regulators measure never events to assess hospital safety culture and dictate reimbursement. The authors suggest that regulators focus on reducing the national never event rate through shared learning and an integrated system-wide approach, rather than concentrating on underperforming, outlier hospitals where factors such as safety culture maybe contributing to increased rates of never events.
Omar I, Singhal R, Wilson M, et al. Int J Qual Health Care. 2021;33:mzab045.
Never events, a significant type of adverse event, should never occur in healthcare. This study analyzed 797 surgical never events that occurred from April 2012 to February 2020 in the National Health Service (NHS) England and categorized them into three main categories: wrong-site surgery (53.58%), retained items post-procedure (44.54%), and wrong implant/prosthesis (1.88%). In total 56 common general surgery never events have been found. Being aware of the common themes may help providers to develop more effective strategies to prevent these adverse events.
Yonash RA, Taylor M. Patient Safety. 2020;2:24-39.
Wrong-site surgeries can lead to serious patient harm and are considered never events by the National Quality Forum. Based on events reported to the Pennsylvania Patient Safety Reporting System between 2015 and 2019, the authors identified an average of 1.42 wrong-site surgery events per week and found that three-quarters of events resulted in temporary or permanent patient harm. The authors present several evidence-based strategies to reduce the likelihood of wrong-site surgery, including preoperative and intraoperative verification, site marking, and timeouts.  
Anderson JE, Watt AJ. Int J Qual Health Care. 2020;32:196-203.
Using a Safety-II framework, the authors used a mixed-methods approach to retrospectively analyze root cause analysis (RCA) reports of ‘never events’ occurring in the United Kingdom to characterize proposed actions, insights and recommendations to prevent future events. The analysis found that proposed actions were generally of low-to-moderate effectiveness, and that despite identifying systems challenges and weaknesses, many reports did not include proposed actions to mitigate or remove risks. The authors conclude that applying concepts from resilient healthcare can identify vulnerabilities and opportunities for strengthening the RCA system and improving the quality of RCA reports.
Geraghty A, Ferguson L, McIlhenny C, et al. J Patient Saf. 2020;16.
Operating room list errors are often cited as leading to wrong-side, wrong-site or wrong-procedure errors. This retrospective study analyzed two years of data from the United Kingdom and found that while no wrong-side, wrong-site or wrong-procedure surgeries were performed during the period, 0.29% of cases (86 cases) included a list error. Wrong-side list errors accounted for the majority of all list errors (72%). Tracking and reducing operating room list errors may help to prevent wrong-side, -site, or -procedure errors.
Graham C, Reid S, Lord TC, et al. Br Dent J. 2019;226:32-38.
Reporting and avoidance of “never events,” such as a wrong tooth extraction, is important for providing consistently safe dental care. This article describes changes made in safety procedures, including introducing surgical safety briefings or huddles in an outpatient oral surgery unit of the United Kingdom’s National Health Service, that eliminated never events for more than two years.
Patient Safety Primer September 7, 2019
Few medical errors are as terrifying as those that involve patients who have undergone surgery on the wrong body part, undergone the incorrect procedure, or had a procedure intended for another patient. These "wrong-site, wrong-procedure, wrong-patient errors" (WSPEs) are rightly termed never events.