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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 - 6 of 6 Results
Carmack A, Valleru J, Randall KH, et al. Jt Comm J Qual Patient Saf. 2022;Epub Sep 30.
Retained surgical items (RSI) are a never event, a serious and preventable event. After experiencing a high rate of RSIs, this United States health system implemented a bundle to reduce RSI, improve near-miss reporting, and increase process reliability in operating rooms. The bundle consisted of five elements: surgical stop, surgical debrief, visual counters, imaging, and reporting.
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 May 1, 2006
A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.