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.

Search All Content

Clear all filter(s)

Clear all filter(s)

Displaying 1 - 20 of 1640 Results

Fast tracking in cardiac surgery: is it safe?

Save to Library

MacLeod JB, D’Souza K, Aguiar C, et al. J Cardiothorac Surg. 2022;17:69.

Post-operative complications can lead to increased length of hospital stay, cost, and resource utilization. This retrospective study compared “fast track” patients (patients extubated and transferred from ICU to a step-down unit the same day as their procedure) and patients who were not fast tracked. Results showed fast track pathways led to a reduction in ICU and overall hospital length of stay and similar post-operative outcomes.

Barriers and enablers to nurses' use of harm prevention strategies for older patients in hospital: a cross-sectional survey.

Save to Library

Redley B, Taylor N, Hutchinson AM. J Adv Nurs. 2022;78:3710-3720.

Nurses play a critical role in reducing preventable harm among inpatients. This cross-sectional survey of nurses working in general medicine wards identified both enabling factors (behavioral regulation, perceived capabilities, and environmental context/resources) and barriers (intentions, perceived consequences, optimism, and professional role) to implementing comprehensive harm prevention programs for older adult inpatients.

Patient falls in the operating room setting: an analysis of reported safety events.

Save to Library

Tan J, Krishnan S, Vacanti JC, et al. J Healthc Risk Manag. 2022;42:9-14.

Inpatient falls are a common patient safety event and can have serious consequences. This study used hospital safety reporting system data to characterize falls in perioperative settings. Falls represented 1% of all safety reports between 2014 and 2020 and most commonly involved falls from a bed or stretcher. The author suggests strategies to identify patients at high risk for falls, improve fall-related training for healthcare personnel, and optimize equipment design in perioperative areas to prevent falls.

Central venous catheter guidewire retention: lessons from England's never event database.

Save to Library

Mariyaselvam MZA, Patel V, Young HE, et al. J Patient Saf. 2022;18:e387-e392.

A retained foreign object can lead to serious clinical consequences and is considered a never event. Researchers analyzed a national patient safety incident database to identify factors contributing to guidewire retention and potential preventative measures. Findings indicate that most retained guidewires are identified after the procedure. The authors suggest that system changes or design modifications to central venous catheter equipment is one approach to prevent guidewire attention.

APSF endorsed statement on revising recommendations for patient monitoring during anesthesia.

Save to Library

The APSF Committee on Technology. APSF Newsletter. 2022;37(1):7–8.

Variation across standards and processes can result in misunderstandings that disrupt care safety. This guidance applied expert consensus to examine existing anesthesia monitoring standards worldwide. Recommendations are provided for organizations and providers to guide anesthesia practice in a variety of environments to address patient safety issues including accidental patient awareness during surgery.

Patient Safety Authority Annual Reports.

Save to Library

Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.

This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.

Intraosseous Line Extravasation in a Pediatric Trauma Patient

Save to Library

WebM&M Case April 27, 2022

An 18-month-old girl presented to the Emergency Department (ED) after being attacked by a dog and sustaining multiple penetrating injuries to her head and neck. After multiple unsuccessful attempts to establish intravenous access, an intraosseous (IO) line was placed in the patient’s proximal left tibia to facilitate administration of fluids, blood products, vasopressors, and antibiotics. In the operating room, peripheral intravenous (IV) access was eventually obtained after which intraoperative use of the IO line was restricted to a low-rate fluid infusion.

Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room

Save to Library

WebM&M Case April 27, 2022

This WebM&M describes an adverse event due to mislabeling or “syringe swap” in a preoperative patient. The commentary outlines several recommendations and safeguards to ensure that medications administration is safe.

Effect of the surgical safety checklist on provider and patient outcomes: a systematic review.

Save to Library

Armstrong BA, Dutescu IA, Nemoy L, et al. BMJ Qual Saf. 2022;31:463-478.

Despite widespread use of surgical safety checklists (SSC), its success in improving patient outcomes remains inconsistent, potentially due to variations in implementation and completion methods. This systematic review sought to identify how many studies describe the ways in which the SSC was implemented and completed, and the impact on provider outcomes, patient outcomes, and moderating factors. A clearer positive relationship was seen for provider outcomes (e.g., communication) than for patient outcomes (e.g., mortality).

Performance variability in perioperative sentinel events: report on a nationwide data set.

Save to Library

Reijmerink IM, Bos K, Leistikow IP, et al. Br J Surg. 2022;109:573-575.

Organizational, environmental, and work-related factors can contribute to performance variations and human error during healthcare delivery. This study examined perioperative sentinel events reported to a Dutch database over a one-year period. It found that although performance variability continued in almost all events, it was rarely explicitly mentioned in incident reports or represented in resulting improvement measures. The authors suggest that explicitly addressing performance variability in sentinel event analyses can lead to more effective improvement measures that account for human performance in healthcare.

Hospital acquired infections in surgical patients: impact of COVID-19-related infection prevention measures.

Save to Library

Tham N, Fazio T, Johnson D, et al. World J Surg. 2022;46:1249-1258.

The COVID-19 pandemic led to changes in infection control and prevention measures to limit nosocomial spread. This retrospective cohort study found that escalations in infection prevention and control practices due to the COVID-19 pandemic did not affect the incidence of other hospital-acquired infections among surgical patients at one Australian hospital. The authors posit that this may be due to high compliance with existing infection prevention and control practices pre-pandemic.

What are we missing? The quality of intraoperative handover before and after introduction of a checklist.

Save to Library

Lane S, Gross M, Arzola C, et al. Can J Anaesth. Epub 2022 Mar 22.

Intraoperative anesthesia handovers can increase patient safety risks. Based on video-recorded handovers and anesthetic records, researchers at this tertiary care center found that introduction of an intraoperative handover checklist improved handover completeness, which may decrease risk for adverse events.

Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management.

Save to Library

Institute for Healthcare Improvement.

Crisis management skills are valuable at both the organizational and clinical levels. This curated set of materials supports leadership engagement in the proactive development and implementation of crisis management plans as a part of larger culture of safety efforts. Key elements covered support respectful communication with patients, families and clinicians after medical errors occur.

Five-year audit of adherence to an anaesthesia pre-induction checklist.

Save to Library

Fuchs A, Frick S, Huber M, et al. Anaesthesia. 2022;77:751-762.

Pre-procedure checklists have been shown to improve patient safety but they are still not utilized in all situations. Analysis of five years of airway management checklist use in operating room, non-operating room, and emergency procedures showed increasing adherence to checklist use, but completion varied by time of day, location, and urgency of procedure. Further research into causes for these variations is recommended.

Association between operative autonomy of surgical residents and patient outcomes.

Save to Library

Oliver JB, Kunac A, McFarlane JL, et al. JAMA Surg. 2022;157:211-219.

Physician autonomy is an important component to medical training, but carries risks to patient safety. This retrospective cohort study used VA Surgical Quality Improvement Program (VASQIP) data from July 2004 through September 2019 to examine resident operative autonomy impacts patient outcomes. Findings indicate that surgical procedures performed by residents alone were not associated with higher rates of mortality or morbidity compared to procedures performed with the assistance of attending surgeons or by attending surgeons alone.

Cost of health care-associated infections in the United States.

Save to Library

Forrester JD, Maggio PM, Tennakoon L. J Patient Saf. 2022;18:e477-e479.

Healthcare-associated infections (HAIs) result in poorer patient outcomes and increased costs. The 2016 national data set of five common HAIs (surgical site infections, catheter- and line-associated bloodstream infections, catheter-associate urinary tract infections, ventilator-associated pneumonia, and Clostridioides difficile) was analyzed to create an estimated national cost. Clostridioides difficile was the most frequently reported; Clostridioides difficile and surgical site infections accounted for 79% of costs.

Surgeon burnout, impact on patient safety and professionalism: a systematic review and meta-analysis.

Save to Library

Al-Ghunaim TA, Johnson J, Biyani CS, et al. Am J Surg. 2022;224:228-238.

Burnout in healthcare providers has been linked to lower patient safety and increased adverse events. This systematic review examined studies focusing on the relationship between burnout and patient safety and professionalism in surgeons. Results indicate higher rates of burnout and emotional exhaustion were associated with an increased risk of involvement in medical error. Interventions to reduce burnout and improve surgeon well-being may result in improved patient safety.

Adverse event and complication tracking in anaesthesiology: dependence on self-reporting despite implementation of electronic health records.

Save to Library

Tewfik G, Naftalovich R, Kaushal N, et al. Br J Anaesth. 2022;128:e28-e32.

Adverse event reporting and tracking are essential components to safety improvement. This letter to the editor summarizes the barriers to accurate adverse event tracking in anesthesiology, including fear of blame or lack of education regarding the importance of identifying reportable events, and the role of Anesthesia Information Management Systems for improving incident reporting and tracking.

Predictive power of the "trigger tool" for the detection of adverse events in general surgery: a multicenter observational validation study.

Save to Library

Pérez Zapata AI, Rodríguez Cuéllar E, de la Fuente Bartolomé M, et al. Patient Saf Surg. 2022;16:7.

Trigger tools are one method of retrospectively detecting adverse events. In this study, researchers used data from 31 Spanish hospitals to validate a trigger tool in general and gastrointestinal surgery departments. Of 40 triggers, 12 were identified for optimizing predictive power of the trigger tool, including broad spectrum antibiotherapy, unscheduled postoperative radiology, and reintervention.

Intraoperative deaths: who, why, and can we prevent them?

Save to Library

Dorken Gallastegi A, Mikdad S, Kapoen C, et al. J Surg Res. 2022;274:185-195.

While interoperative deaths (IODs) are rare, they are catastrophic events. This study analyzed five years of data on IODs from a large academic medical center. The authors describe three phenotypes: patients with traumatic injury, those undergoing non-trauma-related emergency surgery, and patients who die during an elective procedure from medical cardiac arrests or vascular injuries. This classification framework can serve as a foundation for future research or quality improvement processes.

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The PSNet Collection: All Content

Search All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users