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.
Smits M, Groenewegen PP, Timmermans D, et al. BMC Emerg Med. 2009;9:16.
Emergency department (ED) patients are particularly vulnerable to adverse events, and a prior study of closed malpractice claims implicated systems factors such as poor teamwork in adverse patient outcomes. This study used root cause analysis of incident reports to identify the types and causes of errors and unanticipated events in the ED. Incidents included poor communication and teamwork, particularly with other departments, but medication errors and diagnostic errors were also noted. The authors recommend that organizations integrate the ED into hospital-wide safety improvement efforts.