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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 20 Results
Fearon NJ, Benfante N, Assel M, et al. Jt Comm J Qual Patient Saf. 2020;46:410-416.
Opioid prescriptions are associated with harm among postoperative patients. This quality improvement project reduced and standardize opioid prescriptions upon discharge for opioid-naive patients undergoing oncologic surgery and evaluated the impact on subsequent opioid use and reported pain. Pre-standardization, the median opioid prescription at discharge was 20 pills (up to 140 milligrams morphine equivalent, or MME); post-standardization, prescriptions were set to 7-10 pills (24-75 MME) depending on the type of oncologic surgery.
Buissonniere M. Brooklyn NY: Lifebox and Ariadne Labs; 2020.
Checklists are integrated into error reduction strategies and healthcare team communication efforts worldwide but implementation and impact of the tool varies widely. This report examines the use of the WHO Surgical Safety Checklist and barriers to its uptake which include lack of effective staff introduction to the content, misperceptions about the time needed to use the tool and ineffective local contextualization of the content and process.
Davis KK, Mahishi V, Singal R, et al. J Clin Med Res. 2019;11:7-14.
Ambulatory surgery centers are increasingly utilized to provide surgical care to patients. Quality improvement approaches utilized in the inpatient setting may need to be modified or adapted to be applicable in the ambulatory surgery environment. Researchers describe efforts to implement a surgical safety checklist and infection control techniques across 665 ambulatory surgery centers recruited for the study. They identified several barriers and conclude that the unique aspects of ambulatory surgery centers must be taken into account when implementing quality improvement initiatives.
Criscitelli T. AORN J. 2016;103:518-21.
Alarms contribute to distractions, fatigue, and lack of concentration, which can result in patient harm. This commentary examines the problem in ambulatory surgery centers and summarizes resources and recommendations currently available to help staff manage alarms in this setting.
Shapiro FE, Fernando RJ, Urman RD. J Healthc Risk Manag. 2014;33:35-43.
Checklists are an important patient safety intervention in surgery, but existing research has examined their effectiveness only for hospital-based procedures. Although the rate of serious errors in office-based procedures is likely fairly low, safety practices are not standardized in this setting. This survey found that only half of offices performing procedures (which included plastic surgery, gastroenterology, gynecology, and dentistry offices) utilized any type of safety checklist. The main barriers to using checklists were lack of a regulatory mandate and insufficient evidence supporting their effectiveness in this area. A past AHRQ WebM&M commentary discussed a serious error that occurred after a liposuction procedure performed in a plastic surgery office.
Morgan PJ, Cunningham L, Mitra S, et al. Can J Anaesth. 2013;60:528-38.
An attempt to adapt the World Health Organization's surgical safety checklist to ambulatory surgery was unsuccessful, as operating room staff failed to use the checklist consistently. The authors ascribe this result to staff perceptions that the checklist was overly long and had been imposed without a clear rationale.
Commission J. Sentinel event alert. 2013:1-3.
The cacophony of alarms in hospitals has led many health care providers to become desensitized to them, a condition known as alarm fatigue. This sentinel event alert describes how ignoring alarms can have fatal outcomes and recounts an intensive care unit death due to providers' lack of response to alarms signaling a patient's clinical decline. The sentinel event database includes 98 alarm-related events (80 of which resulted in death) between 2009 and June 2012. Because the database relies on voluntary reporting, this number likely represents a small proportion of actual events. The report outlines recommendations and potential strategies for improvement, including guideline development, training and education, and establishment of a cross-disciplinary team of clinicians, clinical engineers, information technologists, and risk managers focused on alarm safety. The Joint Commission is also considering developing a related National Patient Safety Goal to address this issue.
Oakbrook Terrace, IL: Joint Commission Resources; 2010. ISBN: 9781599404073.
This report makes recommendations and provides strategies to ensure safe practice in surgical care.
Erickson TB, Kirkpatrick DH, DeFrancesco MS, et al. Obstet Gynecol. 2010;115:147-51.
This piece reports findings from a panel convened to pinpoint patient safety concerns, provide guidance, and develop strategies to ensure safety for gynecologic surgery procedures performed in the outpatient setting.
Perspective on Safety May 1, 2006
Over the last decade, surgical operations and interventional procedures have been performed increasingly in offices with the administration of office-based anesthesia (OBA).(1) Economic considerations and convenience have driven this increase. Schultz...