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.
This news article reports an independent analysis of patient risk at hospitals that provide surgeries they infrequently perform, highlighting how high procedure volume and the presence of an experienced surgical team at a hospital can enhance the safety of surgical care delivered.
Dubeck D. PA-PSRS Patient Saf Advis. September 2014;11:93-101.
Research has documented a substantial learning curve for surgeons as they develop skills to use robotic technologies. Drawing from data submitted to the Pennsylvania Patient Safety Authority, this article analyzes the 722 safety events involving robotic-assisted surgery reported since 2005—approximately 75% of these incidents did not result in harm but 10 patient deaths were recorded—and discusses the challenges introduced as robotic-assisted surgery becomes accepted as standard surgical practice.
Egerton B. Dallas Morning News. November 14, 2010;A01.
This newspaper article investigates how surgical errors and postoperative complications affected one woman’s life and discusses factors that contributed to the errors, including ineffective trainee supervision.
This newspaper article reveals how one teaching hospital facilitated error through ineffective resident training, weak oversight, and poor safety culture.
This newspaper article discusses complications associated with surgical robots, and explains that such errors may have been exacerbated by inadequate clinician training and production pressures.
This newspaper column explains how simulation training is being integrated into medical education to help clinical teams improve their skills and ensure patient safety.
This news piece reports on wrong-site and wrong-patient surgery and describes efforts to prevent surgical errors following a Joint Commission sentinel event alert on the topic.
Flawed safety standards, including a lack of peer review and oversight, led to a series of errors in a cancer unit at a Philadelphia Veterans Affairs hospital.
This article describes how one health system markedly improved its quality and safety by applying a safety technique used in the nuclear power industry.
This newspaper article discusses increasing concerns over potential burn injuries in the hospital setting and reports on efforts to raise awareness of the dangers and promote preventative measures.
This article investigates the causes of surgical errors reported in recent years by Massachusetts hospitals, and identifies team training and instrument bar-coding as solutions for improvement.
This article reports on an award recognizing Beth Israel Deaconess Hospital for its approach to improving patient safety in response to the death of an infant in 2000.
The authors describe the complexity of keeping current on new anesthesia equipment and propose an in-depth process for physician and technician training to ensure safe use in the operating room.
This article reports on the efforts of one woman, whose mother was severely burned during a tracheostomy, to educate others about and reduce the risk of surgical fires.