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, collaborative initiatives, teamwork, and trigger tools.
Abraham J, Pfeifer E, Doering M, et al. Anesth Analg. 2021;132:1563-1575.
Intraoperative handoffs between anesthesiologists are frequently necessary but are not without risk. This systematic review of 14 studies of intraoperative handoffs and handoff tools found that use of handoff tools has a positive impact on patient safety. Additional research is needed around design and implementation of tools, particularly the use of electronic health records to record handoffs.
Chaudhry H, Nadeem S, Mundi R. Clin Orthop Relat Res. 2021;479:47-56.
The COVID-19 pandemic has dramatically increased the use of telehealth across various medical specialties.This systematic review did not identify any differences in patient or surgeon satisfaction or patient-reported outcomes with telehealth for orthopedic care delivery as compared to in-person visits.However, the authors note that the included studies did not adequately capture or report safety endpoints, such as complications or missed diagnoses.
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.
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.
A woman with a history of chronic obstructive pulmonary disease underwent hip surgery and experienced shortness of breath postoperatively. A chest radiograph showed a pneumothorax, but the radiologist was unable to locate the first call physician to page about this critical finding.
Agarwala A, Firth PG, Albrecht MA, et al. Anesth Analg. 2015;120:96-104.
In this before-and-after study, implementation of a checklist to improve handoffs between anesthesiologists led to better information transfer and enhanced provider satisfaction. These findings echo prior studies of structured handoff communication.
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.
Nagpal K, Vats A, Ahmed K, et al. Ann Surg. 2010;252:402-7.
Communication failures are common in surgical care. This study used a novel assessment tool to evaluate information handoff during the preoperative, intraoperative, and postoperative periods, and found significant problems in each phase.
Cima RR, Hale C, Kollengode A, et al. Arch Surg. 2010;145:641-6.
Wrong-site surgeries are a rare yet devastating complication for patients. Despite efforts to reduce the risk through adoption of Joint Commission’s Universal Protocol and implementation of briefings, these events continue to occur. This study explored a less understood risk for wrong-site surgery by focusing on the documentation transition from outpatient settings to the operating room. Investigators found a 1.4% error rate between the surgical listing and the performed procedure. While no wrong-site surgeries occurred, there were nearly 800 cases where this potential was noted and caught prior to surgery. The error rate was constant across specialties and most frequently associated with mistakes in laterality. After implementation of an electronic and standardized surgical listing form, the error rate was significantly reduced. Past AHRQ WebM&M commentaries have discussed the factors contributing to a near-miss wrong-site surgery and the role of time outs.
Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.
This government report analyzes the National Health Service's efforts to enhance patient safety and recommends improving certain areas, such as adopting technology, analyzing failure, and ensuring both practitioner education and adequate staffing.
Based on preoperative discussions, a patient undergoing knee replacement expected to receive spinal anesthesia; however, general anesthesia was administered, and the records did not note or explain this change. The patient suffered an unusual complication.
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