Skip to main content

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.

Search All Content

Search Tips
Filter By Author(s)
Advanced Filtering Mode
Date Ranges
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Approach to Improving Safety
Safety Target
Displaying 1 - 20 of 22 Results
May 4, 2023
The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.
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, collaborative initiatives, teamwork, and trigger tools.
Loftus TJ, Tighe PJ, Filiberto AC, et al. JAMA Surg. 2019;155:148-158.
Artificial intelligence (AI) can inform decision making and reduce diagnostic uncertainty. These authors discuss challenges in surgical decision-making– such as complexity, time constraints and uncertainty – and how AI can be leveraged using the EHR and mobile devices to overcome these challenges and augment surgical decision-making.
Shah NA, Jue J, Mackey T. Ann Surg. 2020;271:431-433.
Collecting real-time audio, video, and system data enables identification of process vulnerabilities. This commentary discusses the current state of black box approaches to collect surgical procedure data in situ and highlights challenges to its effective use and implementation to improve surgical safety.
Goldenberg MG, Elterman D. World J Urol. 2019;38:1369-1372.
The perioperative setting is a high-risk environment where process weaknesses and human error can contribute to patient harm. This article discusses strategies to reduce risk of perioperative error, such as standardization and surgical checklists. The authors highlight the use of video technology as a promising strategy to improve perioperative safety.
Hensley NB, Koch CG, Pronovost P, et al. Jt Comm J Qual Patient Saf. 2019;45:190-198.
Following a sentinel wrong-patient event, a multidisciplinary quality improvement team worked to enhance the safety of blood transfusion. The authors report significant improvement in protocol adherence following institution of barcoding and auditing via the electronic health record.
Molina WR, Pessoa R, da Silva RD, et al. Patient Saf Surg. 2017;11:10.
Failure to remove ureteral stents can lead to adverse patient outcomes and increased health care costs. In this study, researchers describe a smartphone application designed to simplify tracking of ureteral stent procedures and removal dates.
McCulloch P, Morgan L, New S, et al. Ann Surg. 2015;265.
Safety culture and work systems influence safety, but it is unclear whether safety improvement efforts should focus on one or both factors. This study sought to improve adherence to the WHO surgical safety checklist and to enhance technical and nontechnical team performance using several safety interventions. One intervention focused on improving safety culture, while another was directed at the work system. Investigators also tested a combined approach. Although both team training and system redesign individually demonstrated improvement, the combined approach was more successful than either individual approach. This finding suggests that in order to truly enhance surgical safety, organizations must invest in both systems and culture interventions.
Nissan J, Campos V, Delgado H, et al. JAMA Surg. 2014;149:1209-10.
The introduction of an automated workflow system, which provides a common display of perioperative data elements to every member of the surgical team, improved operative checklist compliance and nearly doubled the number of cases that started on time. The majority of nurses felt this system enhanced patient safety.
Merry A, Webster CS, Hannam J, et al. BMJ. 2011;343:d5543.
Drug administration errors are a major safety concern in anesthesiology, as even routine cases can require administration of several high-risk medications. In this randomized controlled trial, a novel system for drug administration was evaluated in comparison with usual anesthesia practice. The new system was designed according to human factors engineering principles and included proven safety measures such as barcode medication administration. Although fewer overall errors occurred with the new system, the reduction in administration errors occurred only when barcoding was performed consistently and safety alerts were heeded. The anesthesia field has long been a leader in patient safety, and in fact, some of the earliest studies in the patient safety field evaluated the role of human factors in anesthesia medication administration errors.
Bosma E, Veen EJ, Roukema JA. Br J Surg. 2011;98:1654-1659.
This study noted a 6% error rate for patients admitted to a surgical ward with nearly 70% having little or no clinical consequence. The authors advocate for systematic evaluation of near miss events as key learning opportunities.
Rowlands A, Steeves R. AORN J. 2010;92:410-9.
Preventing surgical instruments from being retained in the patient after surgery has traditionally relied on nurses manually counting instruments used during the procedure. However, this method is not foolproof, and this qualitative study used interviews with operating room personnel to explore reasons for incorrect instrument counts. Not surprisingly, the issues identified are known contributors to safety issues in the operating room, including production pressures, poor communication between physicians and nurses, and overt disruptive behavior. In light of these findings, the authors argue that addressing the persistent problem of retained surgical instruments will require an improvement approach based on safety culture principles.