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.
Tejos R, Navia A, Cuadra A, et al. Aesthetic Plast Surg. 2020;44:1926-1928.
Using a case of mislabeled lab specimens as an example, this article highlights the impact of the COVID-19 pandemic on the delivery of healthcare services and the role of human factors in identifying and preventing medical errors.
Root cause analysis has been widely adopted as a strategy to investigate events, despite questions regarding its effectiveness in health care. This revised pubication provides information about updated approaches to root cause analysis with an emphasis on idenitification of causal and contributing factors. It highlights the use of failure mode and effects analays as a complementary sentinel event examination strategy that enables design of proactive and reactive improvements.