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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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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...
Fuchshuber P, Schwaitzberg S, Jones D, et al. Surg Endosc. 2018;32:2583-2602.
Surgical fires have the potential to cause considerable patient harm. This commentary traces the history and experience of an educational strategy to improve safety of surgical energy device use. The program utilizes strategies such as certification, online curricula, and mandated education to engage the surgical team in skill enhancement. The authors describe an international example to illustrate how this approach can be implemented to augment surgical patient safety.
Rockville, MD: Agency for Healthcare Research and Quality; November 2017.
Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on the success of the Comprehensive Unit-based Safety Program to initiate change. The tools represent practical strategies that helped members of a large-scale collaborative to identify areas of weakness, design improvements, and track the impact of the interventions.
London, UK: Royal College of Surgeons of England; 2016.
Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides information for surgeons to help them identify individual and organizational biases and to address disrespectful behaviors through training and peer support mechanisms.
Fernandez FG, Shahian DM, Kormos R, et al. Ann Thorac Surg. 2019;108:1625-1632.
Enabling clinicians and management to access data can help them uncover weaknesses in practice, determine performance measures, and drive improvements. This commentary introduces a series of upcoming articles that will explore information derived from the Society of Thoracic Surgeons National Database to aid in understanding patient safety hazards in cardiothoracic surgery.
Commission J. Sentinel event alert. 2013:1-5.
Sentinel event alerts are issued periodically by The Joint Commission to identify common or emerging patient safety problems and provide organizations with approaches for addressing these issues. A retained foreign object (RFO)—surgical materials or equipment unintentionally left in a patient's body after completing the operation—is a never event that can have serious clinical consequences. Despite being long recognized as a critical—and preventable—error, RFOs continue to occur, with nearly 800 cases being reported to The Joint Commission between 2005 and 2012. This alert makes several recommendations to help prevent RFOs, including focusing on enhancing the reliability of the traditional manual count of instruments and materials used during a procedure, improving safety culture in the operating room through interventions (e.g., teamwork training), and investigating technological approaches (e.g., bar coding of surgical sponges) to ease identification of potentially missing objects before patients are harmed.

Staender S, ed. Best Pract Res Clin Anaesthesiol. 2011;25(2):109-304.  

This special issue explores safety in anesthesia, including safety culture, incident reporting, and handoffs.

Neuman MD, Martinez EA, eds. Anesthesiol Clin. 2011;29:1-178.  

This special issue includes articles discussing safety in anesthesiology practice as well as quality improvement innovations.
de Vries EN, Prins HA, Crolla RMPH, et al. N Engl J Med. 2010;363:1928-37.
A landmark study in patient safety demonstrated remarkable improvement in surgical outcomes through implementation of a checklist for intraoperative and perioperative care. However, inconsistencies in postoperative care are thought to contribute to persistent variation in surgical outcomes between hospitals. In this controlled study, a comprehensive system for the entire surgical pathway—from admission to discharge—was implemented at six teaching hospitals in the Netherlands, and resulted in significant reductions in both complications and overall mortality. The authors note that the success of their intervention relied as much on developing a culture of safety as on the checklist itself, a point supported by another recent study that achieved significant improvement in surgical outcomes through teamwork training.
Patel SP, Gauger PG, Brown DL, et al. J Am Coll Surg. 2010;211:540-5.
Do resident physicians contribute disproportionately to medical errors? The evidence is mixed, despite the longstanding concern about a purported increase in errors in July, when most new residents start their training. This study compared complication rates in breast reduction surgery between surgical residents and an attending physician, and found no evidence of increased complications in procedures performed primarily by residents with close attending supervision. However, poor supervision of residents has resulted in substandard care in other settings.
633 N. St. Clair St. Chicago, IL, 60611.
This Web site provides information about the Council on Surgical and Perioperative Safety, a group of seven organizations that raises awareness of surgical and perioperative issues, furthers research, provides expert knowledge, and supports collaboration.
Gagliardi AR, Eskicioglu C, McKenzie M, et al. Am J Infect Control. 2009;37:398-402.
This study conducted interviews with surgical division heads and managers of quality improvement and infection control at seven hospitals to highlight thematic strategies for preventing surgical site infections. The authors advocate for a combination of educational initiatives, performance data, explicit accountabilities that trigger action, and engaged champions to succeed in the team-oriented effort.
Association of periOperative Registered Nurses.
This Web site includes information and resources for National Time Out Day, an initiative to raise awareness on the importance of surgical team time outs. The annual observation is in June.