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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 - 11 of 11 Results
Leeftink AG, Visser J, de Laat JM, et al. Ergonomics. 2021:1-11.
Failure mode and effect analysis (FMEA) is widely used to identify latent safety hazards. The authors of this study proposed combining healthcare failure mode and effect analysis (HFMEA) with computer simulation (HFMEA-CS) for prospective risk analysis of complex and potentially harmful processes. Use of HFMEA-CS to analyze medication processes during admission and discharge for patients with a rare adrenal tumor led to a reduction in drug delivery and system errors, as well as increased drug adherence.
Haché M, Sun LS, Gadi G, et al. Paediatr Anaesth. 2020;30:1348-1354.
The Wake Up Safe initiative includes a registry of serious adverse events occurring in pediatric anesthesia. This study analyzed events reported between 2010 and 2015. The most common anesthesia-related events were medication events, respiratory complications, and cardiac events. Approximately 85% of these events were considered to be preventable.  
Williams GD, Muffly MK, Mendoza JM, et al. Anesth Analg. 2017;125:1515-1523.
Underreporting of adverse events is a known shortcoming of incident reporting systems. This pre–post study demonstrated an increase in reporting of perioperative adverse events through a multifaceted intervention that included interviewing clinicians about barriers to reporting and creating a local requirement to complete adverse event reports using an electronic incident reporting system. The study team concluded that mandated reporting addresses underuse of incident reporting systems.
Vadera S, Griffith SD, Rosenbaum BP, et al. J Surg Educ. 2015;72:1209-16.
This pre-post study examines the effects of the 2003 ACGME duty hours reform on medication errors among hospitalized surgical patients. The authors hypothesized that the increase in handoffs and a changing attitude toward work—also referred to as a shift-work mentality—might lead to an increase in medication errors. Using the Nationwide Inpatient Sample, a representative sample of hospitalizations maintained by AHRQ's Healthcare Cost and Utilization Project, investigators compared medication error rates for surgical patients between 2000–2003 versus 2003–2011, accounting for trends over time and patient and hospital level covariates. Error rates for teaching hospitals were higher than expected based on patient and hospital characteristics, leading the researchers to conclude that duty hour reform increased medication errors. The magnitude of the effect was modest, and only reached statistical significance for 2 of the 8 years they examined. The effects of duty hours on safety remain controversial, without a clear consensus.
Murff HJ, FitzHenry F, Matheny ME, et al. JAMA. 2011;306:848-55.
Many adverse event identification methods cannot detect errors until well after the event has occurred, as they rely on screening administrative data or review of the entire chart after discharge. Electronic medical records (EMRs) offer several potential patient safety advantages, such as decision support for averting medication or diagnostic errors. This study, conducted in the Veterans Affairs system, reports on the successful development of algorithms for screening clinicians' notes within EMRs to detect postoperative complications. The algorithms accurately identified a range of postoperative adverse events, with a lower false negative rate than the Patient Safety Indicators. As the accompanying editorial notes, these results extend the patient safety possibilities of EMRs to potentially allow for real time identification of adverse events.
Frey B, Ersch J, Bernet V, et al. Qual Saf Health Care. 2009;18:446-9.
Parents of hospitalized children feel personally responsible for their children's safety, and efforts are being made to engage parents in safety efforts. This retrospective review of incident reports found more than 100 cases in a 5-year period in which parents were directly involved in adverse events in a pediatric intensive care unit. These included cases where parents detected an adverse event as well as cases where the parents caused the adverse event (for example, by accidentally disconnecting equipment). The authors advocate for development of a safety culture that encourages parents to report concerns, a goal that is a major focus of the Josie King Foundation.
Cranshaw J, Gupta KJ, Cook TM. Anaesthesia. 2009;64:1317-23.
This study analyzed nearly a hundred claims alleging patient harm and categorized them by error type, with the most frequent being drug administration errors. Investigators surmised that less than half the claims could have been prevented by using recommended double checking processes.
Bhananker SM, Posner KL, Cheney FW, et al. Anesthesiology. 2006;104:228-234.
Using closed malpractice claims from a previously described database, this study discovered significant patient injury associated with monitored anesthesia care (MAC) and a liability profile similar to that of general anesthesia. Investigators performed a detailed analysis of more than 120 MAC claims, compared them with those of general and regional anesthesia, and report on the claim characteristics. MAC claims involved older and more ill patients, with respiratory depression being the most frequent occurrence leading to patient injuries. The authors conclude that more than half of the claims would be preventable with improved monitoring strategies.