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 53 Results

Failure to rescue as a patient safety indicator for neurosurgical patients: are we there yet?

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Roy JM, Rumalla K, Skandalakis GP, et al. Neurosurg Rev. 2023;46:227.

Failure to rescue (FTR) quality metrics measure the ability of healthcare teams and hospitals to prevent mortality following a major complication. This systematic review included 12 studies and examined how FTR has been used in neurosurgical populations. The authors discuss several modifications to existing FTR definitions to better suit neurosurgical patients, such as incorporating measures of baseline frailty.

Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas.

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Washington, DC: The Veterans Affairs Inspector General. October 4, 2023. Report No. 23-00080-227.

Wrong-site surgery and unintentionally retained surgical items are considered never events. This report details five wrong-site surgeries and three instances of retained surgical items at one VA medical center between 2018 and 2022. The findings suggest that timely investigation into events from 2018-2021 may have prevented three incidents in 2022. Additionally, the medical center failed to fully report the provider responsible for three of the wrong-site surgeries.

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Diagnostic Errors Case Studies

January 19, 2023

The Primary-Care Research in Diagnosis Errors (PRIDE) Learning Network was a Boston-based national effort to improve diagnostic safety. Hosted by the State of Massachusetts’ Betsy Lehman Center, it was led by the Harvard Brigham and Women’s Center for Patient Safety Research and Practice with funding from the Gordon and Betty Moore Foundation. ...

Don’t Bite Your Tongue.

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WebM&M Case December 14, 2022

A 63-year-old woman was admitted to a hospital for anterior cervical discectomy (levels C4-C7) and plating for cervical spinal stenosis under general anesthesia. The operation was uneventful and intraoperative neuromonitoring was used to help prevent spinal cord and peripheral nerve injury. During extubation after surgery, the anesthesia care provider noticed a large (approximately 4-5 cm) laceration on the underside of the patient’s tongue, with an associated hematoma.

Fall prevention with the Smart Socks System reduces hospital fall rates.

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Moore T, Kline D, Palettas M, et al. J Nurs Care Qual. 2023;38:55-60.

Fall prevention is a safety priority in hospital settings. This study found that Smart Socks – socks containing pressure sensors that detect when a patient is trying to stand up – reduced fall rates among patients at risk of falls in one hospital’s neurological and neurosurgical department. Over a 13-month period, investigators observed a decreased fall rate (0 per 1000 patient days) among patients wearing Smart Socks compared to prior to intervention implementation (4 per 1000 patient days).

Using the Global Trigger Tool in surgical and neurosurgical patients: a feasibility study.

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Brösterhaus M, Hammer A, Gruber R, et al. PLoS ONE. 2022;17:e0272853.

Healthcare organizations use trigger tools to identify potential errors or adverse events in the electronic health record (EHR), measure the frequency of errors, and track safety improvements. Three hospitals in Germany conducted a feasibility study of implementing the Institute for Healthcare Improvement (IHI) Global Trigger Tool (GTT) in two general surgery units and one neurosurgery unit. Twenty-two feasibility criteria were developed (low-, moderate-, problematic-level of challenge) which may help guide successful implementation of the GTT.

Effect of a pharmacy-based centralized intravenous admixture service on the prevalence of medication errors: a before-and-after study.

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Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. J Patient Saf. 2022;18:e1181-e1188.

Intravenous admixture preparation errors (IAPE) in hospitals are common and may result in harm if they reach the patient. In this before-and-after study, IAPE data were collected to evaluate the safety of a pharmacy-based centralized intravenous admixture service (CIVAS). Compared to the initial standard practice (nurse preparation on the ward), IAPE of all severity levels (i.e., potential error, no harm, harm) decreased and there were no errors in the highest severity level after implementation of CIVAS.

Not ‘just depression.’ She seemed trapped in a downward mental health spiral. The real cause was a profound shock.

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Boodman SG. Washington Post. January 23, 2021.

Misdiagnosis can endure over a long period and delay a correct course of treatment. This news feature shares an example of depression misdiagnosis that masked the true problem of a neurological tumor manifesting in what was seen and treated as a psychological condition.

Preventing Complications during Aneurysm Clipping – the Role of Neuromonitoring.

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WebM&M Case October 28, 2020

A 73-year-old female underwent a craniotomy and aneurysm clipping to resolve a subarachnoid hemorrhage due to a ruptured aneurysm. The neurosurgery resident confirmed the presence of neuromonitoring with the Operating Room (OR) front desk but the neuromonitoring technician never arrived and the surgeon – who arrived after the pre-op huddle – decided to proceed with the procedure in their absence. Although no problems were identified during surgery, the patient emerged from anesthesia with left-sided paralysis, and post-op imaging showed evidence of a new stroke.

Clinical efficacy of combined surgical patient safety system and the World Health Organization's checklists in surgery: a nonrandomized clinical trial.

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Storesund A, Haugen AS, Flaatten H, et al. JAMA Surg. 2020;155:562-570.

This study assessed the impact of combined use of two surgical safety checklists on morbidity, mortality, and length of stay – the Surgical Patient Safety System (SURPASS) is used to address preoperative and postoperative care, and the World Health Organization surgical safety checklist (WHO SSC) is used for perioperative care. In addition to existing use of the WHO SSC, the SURPASS checklist was implemented in three surgical departments in one tertiary hospital in Norway. Results demonstrated that combined use of these checklists was associated with reduced complications reoperations, and readmissions, but combined use did not impact mortality or length of stay.

Spinal surgery complications: an unsolved problem-Is the World Health Organization Safety Surgical Checklist an useful tool to reduce them?

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Barbanti-Brodano G, Griffoni C, Halme J, et al. Eur Spine J. 2019.

Checklists are one tool for improving communication and reducing risk of adverse outcomes. The World Health Organization Surgical Safety Checklist has been previously studied in various surgical specialties; this study sought to determine its effectiveness in spinal surgeries. The authors conducted a retrospective analysis comparing the incidence of complications pre-checklist and post-checklist in a single center and found a significant reduction in the overall incidence of complications after the introduction of the checklist.

The introduction of a Neurosurgical Postoperative Checklist improved quality of care and patient safety.

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Hall AJ, Toner NS, Bhatt PM. Br J Neurosurg. 2019;33:495-499.

Research has found that checklists can improve patient safety in various surgical specialties but their use in neurosurgery is limited. This single center study implemented a neurosurgical postoperative checklist, which resulted in more patients undergoing a postoperative review and increases in appropriate medication prescribing.

The need for surgical safety checklists in neurosurgery now and in the future - a systematic review.

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Westman M, Takala R, Rahi M, et al. World Neurosurg. 2019.

Checklists have been shown to improve patient safety in various surgical specialties but this systematic review found that evidence of their impact in neurosurgery is still limited given emerging technologies such as robotics and artificial intelligence. Studies with larger neurosurgical patient populations, as well as in relation to robotic neurosurgery, are needed to understand the impact of checklists in neurosurgery.

Spinal Epidural Abscess

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WebM&M Case August 8, 2019

A woman with a history of prior spine surgery presented to the emergency department with progressive low back pain. An MRI scan of T11–S1 showed lumbar degenerative joint disease and a small L5–S1 disc herniation. She was referred for physical therapy and prescribed muscle relaxant, non-steroidal anti-inflammatories, and pain relievers. Ten days later, she presented to a community hospital with fever, inability to walk, and numbness from the waist down. Her white blood cell count was greater than 30,000 and she was found to be in acute renal and liver failure.

Missed opportunities for diagnosing brain tumours in primary care: a qualitative study of patient experiences.

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Walter FM, Penfold C, Joannides A, et al. Br J Gen Pract. 2019;69:e224-e235.

This qualitative study of 39 patients with a recent diagnosis of brain tumor found that many had multiple primary care visits prior to diagnosis, raising concern for missed opportunities for diagnosis. Patients reported more prompt diagnosis when their primary care physician elicited a more comprehensive history including subtle cognitive changes. The authors conclude that better public awareness of symptoms could prompt more timely diagnosis of brain tumors.

A surgeon so bad it was criminal.

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Beil L. ProPublica. October 2, 2018.

This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted in patient harm. A past PSNet perspective explored the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.

Changing operating room culture: implementation of a postoperative debrief and improved safety culture.

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Magill ST, Wang DD, Rutledge C, et al. World Neurosurg. 2017;107:597-603.

Postoperative debriefing is a strategy to improve teamwork. This pre–post study found that safety culture, as measured by the Safety Attitudes Questionnaire, improved after implementation of postoperative debriefing at a single center's neurosurgery service.

Association of overlapping surgery with patient outcomes in a large series of neurosurgical cases.

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Howard BM, Holland CM, Mehta C, et al. JAMA Surg. 2018;153:313-321.

Overlapping surgery refers to the practice of surgeons scheduling two procedures performed on different patients concurrently. This practice has raised safety concerns in light of news investigations, which prompted a government inquiry into concurrent surgery policies. This single-center retrospective study of 2275 neurosurgery cases at an academic medical center compared overlapping to nonoverlapping procedures. The majority of surgeries were overlapping, and rates of morbidity and mortality did not differ between overlapping and nonoverlapping cases. These findings suggest that overlapping surgery can be conducted safely.

A lost voice.

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Baker M. Seattle Times. February 10, 2017.

Reporting on an incident involving a patient who died after a surgery, this news article discusses potential contributing factors in the incident such as concurrent surgeries and failure to consider patient and family concerns. A past WebM&M commentary highlighted the importance of listening to families when they advocate for patients in the hospital.

Performance measures in neurosurgical patient care: differing applications of patient safety indicators.

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Moghavem N, McDonald KM, Ratliff JK, et al. Med Care. 2016;54:359-64.

The AHRQ Patient Safety Indicators (PSIs) can identify adverse events in hospital data. This study demonstrated that PSIs were associated with longer hospital stays and increased mortality. Neurosurgery patients were more likely to have PSIs occur than other surgical patients.

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