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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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Approach to Improving Safety
Displaying 1 - 11 of 11 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.
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.
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.
Griffen FD, Stephens LS, Alexander JB, et al. Transactions of the .. Meeting of the American Surgical Association. 2008;126.
Disruptive behaviors are a growing concern in patient safety and system-level solutions remain a challenge. This study adds to those concerns by finding that failures in behavioral practice occurred in nearly 80% of examined closed cases with poor communication accounting for the majority of patient complications.