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.
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization,teamwork, unit-based safety initiatives, and...
A 52-year old women presented to the emergency department with a necrotizing soft tissue infection (necrotizing fasciitis) after undergoing cosmetic abdominoplasty (‘tummy tuck’) elsewhere. A lack of communication and disputes between the Emergency Medicine, Emergency General Surgery and Plastic Surgery teams about what service was responsible for the patient’s care led to delays in treatment. These delays allowed the infection to progress, ultimately requiring excision of a large area of skin and soft tissue.
Lemos C de S, Poveda V de B. J Perianesth Nurs. 2019;34:978-998.
This integrative review examined the factors contributing to perioperative adverse events resulting from anesthesia. Researchers found that both active errors, such as medication errors or inattention, and latent errors, such as communication failures, contributed to adverse events.
Failure to adhere to evidenced-based practices can result in patient harm. This article explores how high reliability concepts can support the reliable use of best practices to prevent surgical site infections. The authors suggest a framework focused on team engagement, education, implementation, and evaluation to encourage the use of evidence-based practice on the front line.
Parker KM, Harrington A, Smith CM, et al. J Nurses Prof Dev. 2016;32:56-63.
Disruptive behavior is common in health care settings. This commentary discusses the development and implementation of a multifaceted initiative to address unprofessional conduct among nurses. The authors highlight the importance of involving the organization, leaders, and individuals in achieving culture change.
Rockville, MD; Agency for Healthcare Quality and Research; March 2016.
Patient safety culture surveys uncover insights into organizational culture and practice areas that require improvement. This selective resource list offers materials for ambulatory surgery centers that seek to implement changes in response to survey results.
Sinnott M, Eley R, Winch S. AORN J. 2014;100:91-5.
This commentary describes a program designed to enhance safety culture in hospitals for patients and health care workers. The author illustrates examples of tools to determine areas for improvement and augment safety behaviors.
Nagelkerk J, Peterson T, Pawl BL, et al. J Interprof Care. 2014;28:358-64.
This study evaluated an interprofessional initiative that incorporated training using didactic, simulation, and safety rounding. Researchers found that didactic training increased safety knowledge and incident reporting, similar to prior studies, and simulation enhanced critical thinking.
Austin, TX: Texas Medical Institute for Technology and the Quaid Foundation; 2010.
This documentary reports on families affected by medical errors; it includes the story of a high-profile heparin overdose and how it transformed the family of actor Dennis Quaid into advocates for patient safety.
Wachter RM, Pronovost PJ. New Engl J Med. 2009;361:1401-1406.
An early focus of the patient safety movement was a shift from the traditional culture of individual blame to one that investigated errors as the failure of systems, popularized by adoption of James Reason's Swiss cheese model of organizational accidents. In recent years, there has been some backlash against a unidimensional systems-focused model, with past commentaries exploring the tension between a "no blame" culture and individual accountability. Articles in this genre have considered this tension in the educational setting, and a popular construct involves a just culture framework, which differentiates "no blame" from blameworthy acts. This commentary, written by two of the leaders in the safety field, further explores the relationship between blame and accountability, discusses why enforcement of safety standards tends to be lax (particularly in cases involving physicians), and proposes a working balance that not only promotes a safety culture but also safe patient care. The authors highlight hand hygiene non-compliance as an example of a behavior that should be managed through an accountability framework, with providers held accountable for failure to adhere to a known safety standard. They also offer suggested penalties (mostly involving suspension of clinical privileges) for repeated failures to comply with hand hygiene and other established safe practices.
Larsen D, Cole R, Higton P. Nurs Stand. 2007;21:35-40.
By introducing several scenarios that illustrate the effective use of a decision-making tree, the authors emphasize the importance of fair response to medication error at both the individual and system levels.
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
A nursing student administers the wrong 'cup' of medications to an elderly man. A different student discovered the error when she reviewed the medicines in her patient's cup and noticed they were the wrong ones.
This UK Department of Health report details a series of errors that led to the death of a young man due to wrong route administration of the chemotherapy drug vincristine. The fatality occurred as a result of a socio-technical systems failure at the hospital where he received the injection. The report makes 48 recommendations to help minimize the likelihood of this mistake.
In February 2003, 17-year-old Jessica Santillan died at Duke University Medical Center due to a mismatched heart-lung transplantation. As with the Dana-Farber experience, the death made headlines around the world and devastated the leaders and providers at...
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
This article explores the science of how adaptive systems respond to internal and external challenges. Drawing from a literature largely from outside health care, the authors discuss the roles of self-adjusting and interactive systems to manage the interdependence between clinical practice, information management, research, education, and professional development. They describe the role unpredictability plays in these systems, and suggest modified conceptual frameworks for the future. This framework necessitates replacing traditional methods of problem solving with ones that both foster respect for autonomy and respond flexibly to emerging patterns and opportunities. This article is the first in a series of four that explored the topic.
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