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.
This retrospective cohort study used root cause analysis (RCA) to examine safety reports from emergency departments at Veterans Health Administration hospitals over a two-year period. Of the 144 cases identified, the majority involved delays in care (26%), elopements (15%), suicide attempts and deaths (10%), inappropriate discharges (10%) and errors following procedures (10%). RCA revealed that primary contributory factors leading to adverse events were knowledge/educational deficits (11%) and policies/procedures that were either inadequate (11%) or lacking standardization (10%).
Kachalia A, Gandhi TK, Puopolo AL, et al. Ann Emerg Med. 2007;49:196-205.
This study addressing the causes of missed and delayed diagnoses in emergency department patients used similar methodology as a companion study of error in the ambulatory setting and a prior study of surgical patients. Errors involved a broad range of patients and conditions. As in the outpatient arena, errors generally occurred due to failure to order diagnostic tests or interpret them correctly; factors contributing to error included cognitive factors (ie, physician judgment or knowledge), but system factors (ie, fatigue or communication breakdowns) were involved in a significant proportion of cases. As was also found in the study of ambulatory patients, the multifactorial nature of the errors identifies many potential areas for action but likely defies simple solutions.
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