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...
In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.
Forster AJ, Fung I, Caughey S, et al. Obstet Gynecol. 2006;108:1073-83.
This study used a trained observer to monitor obstetric patients for potential adverse events. Based on a predefined set of 72 triggers (eg, admission to intensive care unit, stat cesarean delivery, staff unavailability), the observer captured relevant information about the events, which were later analyzed by a multidisciplinary team. Investigators identified more than 100 triggers, and while very few serious adverse events were described, a number of potential adverse events raised questions about system problems. The authors advocate for use of their methodology to complement existing mechanisms in collecting information on adverse events.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.