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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 - 5 of 5 Results
Weston M, Chiodo C. AORN J. 2022;115:569-575.
Unintentionally retained foreign objects can be exacerbated by fatigue, distractions, and communication errors. This article highlights the importance of effective teamwork, high reliability orientation, and standardized surgical count methods to minimize the persistent problem of retained surgical items.
Curated Libraries
January 14, 2022
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...
Krishnan S, Wheeler KK, Pimentel MP, et al. J Healthc Risk Manag. 2022;41:25-29.
Incident reporting systems are used to detect patient safety concerns and determine potential causes and opportunities for improvements. In the perioperative setting of one hospital, insufficient handoffs were the most common event type in the “coordination of care” category. Use of structured handoffs is recommended to improve communication and patient safety.
Ranum D, Beverly A, Shapiro FE, et al. J Patient Saf. 2021;17:513-521.
This analysis of medical malpractice claims identified four leading causes of anesthesia-related claims involving ambulatory surgery centers – dental injuries, pain, nerve damage, and death. The authors discuss the role of preoperative risk assessment, use of routine dental and airway assessment, adequate treatment of perioperative pain, and improving communication between patients and providers.