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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 32 Results
WebM&M Case October 27, 2022

A 47-year-old man underwent a navigational bronchoscopy with transbronchial biospy under general anesthesia without complications. The patient was transferred to the post-acute care unit (PACU) for observation and a routine post-procedure chest x-ray (CXR). After the CXR was taken, the attending physician spoke to the patient and discussed his impressions, although he had not yet seen the CXR. He left the PACU without communicating with the bedside nurse, who was caring for other patients. The patient informed the nurse that the attending physician had no concerns.

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.
Burden AR, Potestio C, Pukenas E. Adv Anesth. 2021;39:133-148.
Handoffs occur several times during a perioperative encounter, increasing the risk of communication errors. Structured handoffs, such as situation-background-assessment-recommendation (SBAR) and checklists, have been shown to improve communication between providers during anesthesia care. The authors discuss how these tools and other processes can improve shared understanding of effective handoffs.
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...
Arshad SA, Ferguson DM, Garcia EI, et al. J Surg Res. 2021;257:455-461.
Engaging patients and families is an important strategy in ensuring safe health care delivery. In this prospective, observational study, use of a parent-centered script did not improve parent engagement during the preinduction checklist and resulted in an expected decline in checklist adherence.  
Gunnar W, Soncrant C, Lynn MM, et al. J Patient Saf. 2020;16:255-258.
Retained surgical items (RSI) are considered ‘never events’ but continue to occur. In this study, researchers compared the RSI rate in Veterans Health (VA) surgery programs with (n=46) and without (n=91) surgical count technology and analyzed the resulting root cause analyses (RCA) for these events. The RSI rate was significantly higher in for the programs with surgical count technology compared to the programs without (1/18,221 vs. 1/30,593). Analysis of RCAs found the majority of incidents (64%) involved human factors issues (e.g., staffing changes during shifts, staff fatigue), policy/procedure failures (e.g., failure to perform methodical wound sweep) or communication errors.
Soncrant C, Mills PD, Neily J, et al. J Patient Saf. 2020;16:41-46.
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.
Patient Safety Primer September 7, 2019
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
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.

Health Aff (Millwood). 2018;37(11):1723-1908.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.
Govindappagari S, Guardado A, Goffman D, et al. J Patient Saf. 2020;16:279-283.
Checklists have been shown to improve safety in the surgical setting. This retrospective chart review examined communication among staff members before and after implementation of an obstetric checklist for cesarean deliveries. Investigators found better agreement about reason for cesarean deliveries among the obstetric, anesthesiology, and pediatric staff after implementation of their checklist.
Pucher PH, Johnston MJ, Aggarwal R, et al. Surgery. 2015;158:85-95.
The Joint Commission and the Accreditation Council for Graduate Medical Education have called for institutions to implement standardized handoff strategies. This systematic review found indications that checklists can improve the quality of care transitions for surgical patients, but the quality of published evidence is low.
Tscholl DW, Weiss M, Kolbe M, et al. Anesth Analg. 2015;121:948-956.
This pre-post study demonstrated increases in teamwork after introduction of an anesthesia checklist. Although evidence for checklists in real-world settings is mixed, this work demonstrates their efficacy as part of an intervention study, which is consistent with prior work.
Jammer I, Ahmad T, Aldecoa C, et al. Br J Anaesth. 2015;114:801-807.
The initial evidence supporting the impact of the World Health Organization's surgical safety checklist was a cohort study that found a significant reduction in mortality associated with the use of the checklist. More recently, the mandated adoption of surgical checklists in Canada failed to show any benefits on surgical outcomes. This retrospective point prevalence study evaluated checklist use in 426 hospitals across 28 European nations, involving more than 45,000 patients undergoing noncardiac inpatient surgery. Notably, there was striking variation in surgical checklist exposure, with checklists used for 0% to 99.6% of patients, depending on the nation. The use of surgical checklists was associated with lower hospital mortality, even after adjusting for risk factors. However, it is unclear from this study whether this improvement is due to the checklist or rather checklist usage is a process measure indicating higher overall perioperative quality. A prior AHRQ WebM&M perspective reviewed best practices for creating effective checklists.
Guglielmi CL, Canacari EG, DuPree ES, et al. AORN J. 2014;99:783-794.
The Universal Protocol has been widely adopted in the decade since its release. Successful utilization of the protocol to prevent wrong-site surgery has been determined to extend beyond checklist use. This commentary features insights from a multidisciplinary panel on their experiences with time outs and why are still needed to ensure safety in surgery.
Treadwell JR, Lucas S, Tsou AY. BMJ Qual Saf. 2014;23:299-318.
Checklists have been responsible for some of the most remarkable successes of the patient safety era, particularly in improving safety for patients undergoing surgery. However, recent studies have raised concern that surgical checklists may not realize their promise in real-world settings. This systematic review, performed originally for the AHRQ Making Healthcare Safer II report, found broad evidence that surgical safety checklists (including the SURPASS checklist and the World Health Organization checklist) are effective at preventing intraoperative and postoperative complications. The review also identifies factors associated with successful implementation of the checklists, information that is essential in order to translate research findings into daily clinical practice.
Bagian JP. Human Factors and Ergonomics in Manufacturing & Service Industries. 2011;22.
Articles in this special issue detail how human factors and ergonomics concepts can contribute to patient safety efforts through improving design, training, and equipment usability.
Nagpal K, Vats A, Lamb B, et al. Ann Surg. 2010;252:225-39.
This systematic review of 38 published studies identified communication failures in all phases of surgical care, including intraoperatively and during postoperative care. Such breakdowns in information transfer, particularly during handoffs, have been linked to adverse events in prior studies. A number of interventions have been proposed to address this issue, including standardized checklists—which were remarkably successful at reducing postoperative complications in a classic study—and incorporation of handoff techniques from other industries. An AHRQ WebM&M commentary discusses the disastrous consequences of an intraoperative communication breakdown.