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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 214 Results
Curated Libraries
September 13, 2021
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...
WebM&M Case August 25, 2021

A seven-year-old girl with esophageal stenosis underwent upper endoscopy with esophageal dilation under general anesthesia. During the procedure, she was fully monitored with a continuous arterial oxygen saturation probe, heart rate monitors, two-lead electrocardiography, continuous capnography, and non-invasive arterial blood pressure measurements.

WebM&M Case July 28, 2021

This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

Minehart RD, Bryant AS, Jackson J, et al. Obstet Gynecol Clin North Am. 2021;48:31-51.
Improving maternal safety and reducing disparities in maternal morbidity and mortality are national priorities. This article discusses inequities in maternal health outcomes and provision of care, factors involved in the relationship between race and health (e.g., racism, social status, health behaviors), and efforts at the national-, state-, and hospital-level to improve obstetric care and outcomes for Black mothers.

AHA Team Training.

The COVID-19 crisis requires cooperation and coordination of organizations and providers to address the persistent challenges presented by the pandemic. This on-demand video collection reinforces core TeamSTEPPS; methods that enhance clinician teamwork and communication skills to manage care safety during times of crisis. 
Lewandowska K, Weisbrot M, Cieloszyk A, et al. Int J Environ Res Public Health. 2020;17:8409.
Alarm fatigue, which can lead to desensitization and threaten patient safety, is particularly concerning in intensive care settings. This systematic review concluded that alarm fatigue may have serious consequences for both patients and nursing staff. Included studies reported that nurses considered alarms to be burdensome, too frequent, interfering with patient care, and resulted in distrust in the alarm system. These findings point to the need for a strategy for alarm management and measuring alarm fatigue.  
WebM&M Case December 23, 2020

After a breast mass was identified by a physician assistant during a routine visit, a 60-year-old woman received a diagnostic mammogram and ultrasound. The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably benign” findings. When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred for a biopsy.

WebM&M Case July 29, 2020

A 28-year-old woman arrived at the Emergency Department (ED) with back pain, bloody vaginal discharge, and reported she had had a positive home pregnancy test but had not received any prenatal care and was unsure of her expected due date. The ED intern evaluating the patient did not suspect active labor and the radiologist remotely reviewing the pelvic ultrasound mistakenly identified the fetal head as a “pelvic mass.” Four hours later, the consulting OB/GYN physician recognized that the patient was in her third trimester and in active labor.

Kremer MJ, Hirsch M, Geisz-Everson M, et al. AANA J. 2019;87.
This thematic analysis identified 123 events comprising malpractice claims in the closed claims database of the American Association of Nurse Anesthetists (AANA) Foundation that the investigators determined could have been prevented by the Certified Registered Nurse Anesthetist involved. Among the factors identified as being associated with preventable events were communication failures, violations of the AANA Standards for Nurse Anesthesia Practice, and errors in judgment.
WebM&M Case December 18, 2019
A 55-year-old man visited his oncologist for a follow-up appointment after completing chemotherapy and reported feeling well with his abdominal and bony pain well controlled with opioid therapy.  At the end of the visit, his oncologist reordered his pain medication and, due to a best practice alert, also prescribed naloxone but failed to provide any instruction on its use. Later that day, the patient took the naloxone along with his opioid pain medication and within a minute experienced severe abdominal and bony pain, requiring admission to the emergency department.
Oakbrook Terrace, IL: Joint Commission: October 2019.
Inpatient suicide is increasing as a safety concern. This case analysis offers two levels of examination of a hypothetical patient suicide: one that outlines points of failure in the patient’s care and the other that shares strategies to prevent the event from occurring. 
Wright B, Faulkner N, Bragge P, et al. Diagnosis (Berl). 2019;6:325-334.
The hectic pace of emergency care detracts from reliability. This review examined the literature on evidence, practice, and patient perspectives regarding diagnostic error in the emergency room. A WebM&M commentary discussed an incident involving a diagnostic delay in the emergency department.
Halperin O, Bronshtein O. Nurse Educ Pract. 2019;36:34-39.
Underreporting of safety events and near misses in the health care setting has been well described and is one of the challenges in using data from incident reporting systems to measure safety. Researchers surveyed nursing students and clinical instructors to identify barriers to reporting and found that fear of negative consequences was a major factor.
Bundy DG, Singh H, Stein RE, et al. Clin Trials. 2019;16:154-164.
Diagnostic errors in pediatric primary care are common and represent an ongoing patient safety challenge. In this stepped-wedge, cluster-randomized trial, researchers were able to successfully recruit a diverse group of pediatric primary care practices to participate in virtual quality improvement collaboratives designed to reduce diagnostic error.
Ogunyemi D, Hage N, Kim SK, et al. Jt Comm J Qual Patient Saf. 2019;45:423-430.
The rise in maternal morbidity and mortality is one of the most pressing patient safety issues in the United States. Formal debriefing after adverse events is an important method for analyzing and improving safety. In this study, an academic hospital adopted a systems-based morbidity and mortality conference model to review cases of serious maternal harm and implemented several safety measures (including teamwork training) to address issues that were identified through structured review.
Srinivasa S, Gurney J, Koea J. JAMA Surg. 2019;154:451-457.
As many as half of all clinicians may be involved in a serious adverse event during their career, and these events may have profound professional consequences. This systematic review examined the effect of patient complications on surgeons' well-being. Patient complications had significant adverse consequences for surgeons' emotional health, to which surgeons responded with coping mechanisms ranging from adaptive (discussing cases with colleagues or utilizing professional support) to maladaptive (alcohol or substance use). Studies reported varying perceptions of institutional support. Many surgeons derived benefit from the support of trusted mentors or senior colleagues after a serious patient complication, but lack of formal organizational support was commonly noted. Surgeons reported taking various corrective actions after a complication, such as personal development and system-level quality improvement efforts. The authors make several recommendations for helping surgeons after complications, including developing formal structures to aid surgeons in the coping process. Books by British neurosurgeon Dr. Henry Marsh and patient safety leader Dr. Atul Gawande explore the professional and personal consequences of adverse events in vivid detail.
Browne AM, Deutsch ES, Corwin K, et al. Am J Med Qual. 2019;34:569-576.
Diagnostic improvement leaders have advocated for emphasis on cognition to reduce failures. This commentary discusses a training initiative to enhance clinician awareness of cognitive bias and team interactions to address decision-making missteps. The authors describe the tools implemented and results of the program, including skill improvement of nonphysician participants.
Lin M, Famiglietti H. Pediatrics. 2019;143.
Disclosure of errors and adverse events is now endorsed by a broad array of organizations. This commentary emphasizes the need to educate trainees about disclosure in pediatric care. The author encourages clinicians to consider the perspectives of patients and families when preparing teams to disclose pediatric errors.
WebM&M Case February 1, 2019
Following surgery under general anesthesia, a boy was extubated and brought to postanesthesia care unit (PACU). Due to the patient's age and length of the surgery, the PACU anesthesiologist ordered continuous pulse-oximetry monitoring for 24 hours. Deemed stable to leave the PACU, the boy was transported to the regular floor. When the nurse went to place the patient on pulse oximetry, she realized he was markedly hypoxic. She administered oxygen by face mask, but he became bradycardic and hypotensive and a code blue was called.