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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 - 20 of 44 Results
Dexter F, Parra MC, Brown JR, et al. Anesth Analg. 2020;131:37-42.
The authors describe eight empirical recommendations for optimizing infection control and operating room (OR) management during the COVID-19 pandemic. Recommendations address (1) hand hygiene, (2) environmental cleaning, (3) patient decolonization, (4) vascular care, (5) surveillance of pathogen transmission, (6) efficient use of personal protective equipment (7) OR scheduling, and (8) postoperative recovery settings.
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.
Ramsay G, Haynes AB, Lipsitz SR, et al. Br J Surg. 2019;106:1005-1011.
Checklists have been shown to improve surgical safety in randomized controlled trials, but they have had varied impact when implemented in clinical practice. This interrupted time-series study examined surgical mortality before, during, and after implementation of the WHO surgical safety checklist. The rate of surgical mortality declined more during checklist introduction than it had before or after implementation, and hospital mortality did not decline among nonsurgical patients during the same time interval. The investigators, including checklist pioneer Atul Gawande, conclude that perioperative mortality has declined in association with checklist implementation. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.
Abbott TEF, Ahmad T, Phull MK, et al. Br J Anaesth. 2018;120:146-155.
Surgical checklists have been shown to improve safety outcomes in randomized trials, but implementation studies have not uniformly demonstrated benefit. This study included a large, multicountry observational cohort of surgical outcomes before and after implementation of a checklist. Mortality declined after checklist implementation, but the rate of postoperative complications remained unchanged. Investigators also conducted a meta-analysis of surgical checklist studies (excluding those that paired the checklist with other interventions) on postoperative mortality and complications. This synthesis of published studies suggests that checklists improved mortality and complications overall. Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists in past PSNet interviews.
Ravi B, Pincus D, Wasserstein D, et al. JAMA Intern Med. 2018;178:75-83.
Overlapping surgery is the practice of surgeons scheduling distinct procedures on different patients concurrently. This practice has raised safety concerns. This large population-based retrospective study examined outcomes for nonoverlapping versus overlapping hip surgeries across Ontario, Canada. After adjustment for factors known to predict surgical outcomes, such as hospital and surgeon case volume and the patient's overall health, researchers found an association between increasing duration of surgical overlap and higher risk of complications. These results contrast with a recent single-center study that found no safety differences between overlapping and nonoverlapping neurosurgeries. An accompanying editorial acknowledges the mixed results of safety studies for overlapping surgeries and calls for large, multicenter, prospective studies across a range of surgical procedures with long-term follow-up.
George BC, Bohnen JD, Williams RG, et al. Ann Surg. 2017;266:582-594.
Insufficient trainee supervision may lead to adverse events, but lack of autonomy may leave trainee physicians unprepared for independent practice. In this direct observation surgical education study, attending physicians rated readiness for independent practice and level of supervision for surgical trainees performing specific core procedures throughout the course of their training. At the end of training, 90% of trainees performed competently on average complexity patients, but this proportion dropped to less than 80% for the most complex cases. For about two-thirds of core procedures, surgical residents still had significant supervision in their last 6 months of training. The authors raise concerns about whether graduating residents have sufficient experience practicing independently to enter clinical practice. A previous PSNet perspective advocated for continued appropriate supervision to augment patient safety.
Haynes AB, Edmondson L, Lipsitz S, et al. Ann Surg. 2017;266:923-929.
Checklists have been shown to reduce surgical morbidity and mortality in randomized trials, but results of implementation in clinical settings have been mixed. This study reports on a voluntary, statewide collaborative program to implement a surgical safety checklist in South Carolina hospitals. Participating sites undertook a multifaceted process to support checklist implementation and culture change. Cross-institutional educational activities were available to all hospitals in the collaborative. Investigators determined that rates of surgical complications declined significantly in hospitals involved in the collaborative compared with those that did not participate, which had no change in postsurgical mortality over the same time frame. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.
Cooper WO, Guillamondegui O, Hines J, et al. JAMA Surg. 2017;152:522-529.
Most patient safety problems can be ascribed to underlying systems failures, but issues with individual clinicians play a role as well. Prior studies have shown that a small proportion of physicians account for a disproportionate share of patient complaints and malpractice lawsuits. This retrospective cohort study used data from the Patient Advocacy Reporting System (which collects unsolicited patient concerns) and the National Surgical Quality Improvement Program to examine the association between patient complaints and surgical adverse events. The investigators found that patients of surgeons who had received unsolicited patient concerns via the reporting system were at increased risk of postoperative complications and hospital readmission after surgery. Although the absolute increase in complication rates was relatively small across all surgeons, surgeons in the highest quartile of unsolicited observations had an approximately 14% higher risk of complications compared to surgeons in the lowest quartile. This study extends upon prior research by demonstrating an association between patient concerns about individual clinicians and clinical adverse events, and it strengthens the argument for using data on patient concerns to identify and address problem clinicians before patients are harmed.
Hyder JA, Hanson KT, Storlie CB, et al. Ann Surg. 2017;265:639-644.
Overlapping surgery refers to when two procedures are performed concurrently, but important portions occur at different times. Experts have raised concerns about the safety of scheduling coincident procedures. This study compared overlapping surgeries with nonoverlapping surgeries of the same type at a single referral center. After adjusting for surgeon and patient characteristics, investigators found no differences in inpatient mortality or length of stay. They performed an analogous analysis in the National Surgical Quality Improvement Program registry medical record data, which resulted in similar findings. Although these results should allay concerns about concurrent surgeries, the authors caution that further studies at multiple centers are needed to ensure that overlapping procedure practices do not carry excess risk to patients.
Vadnais MA, Hacker MR, Shah NT, et al. Jt Comm J Qual Patient Saf. 2016;43:53-61.
Cesarean delivery is associated with increased morbidity, mortality, longer hospital stays, and increased costs. From 2008 through 2015, a single tertiary care academic medical center implemented a quality improvement initiative designed to address factors influencing the rate of nulliparous term singleton vertex (NTSV) cesarean delivery rate. The initiative consisted of provider education, provider feedback, and implementation of new policies. The rate of NTSV cesarean delivery decreased from 34.8% to 21.2% and total cesarean delivery rate decreased from 40.0% to 29.1%. Researchers also noted a decline in the incidence of episiotomy and third-degree lacerations. 
Bilimoria KY, Chung JW, Hedges L, et al. New Engl J Med. 2016;374:713-727.
Resident physician duty hour policies have generated rigorous debate, particularly following the most recent ACGME changes implemented in 2011, which shortened maximum shift lengths for interns and increased time off between shifts. This national study cluster-randomized 118 general surgery residency programs to adhere to current ACGME duty hour policies or to abide by more flexible rules that essentially followed the prior standard of a maximum 80-hour work week. Between these two groups, there were no significant differences in patient outcomes, including death and serious complications. Residents reported similar levels of satisfaction with their overall education quality and their well-being. An accompanying editorial notes that the study authors interpret these results as supporting flexible work-hour rules. Alternatively, the editorial author suggests that this study refutes concerns that the new policy compromises patient safety, and as such there is no compelling reason to backtrack on its implementation.
Fan CJ, Pawlik TM, Daniels T, et al. J Am Coll Surg. 2016;222:122-128.
Safety culture is widely measured and discussed, but its link to patient outcomes has not been consistently demonstrated. Surgical site infections are considered preventable adverse events. In this cross-sectional study, investigators found that better safety culture was associated with lower rates of surgical site infections after colon surgery. Specifically, aspects of safety culture associated with teamwork, communication, engaged leadership, and nonpunitive response to error were linked to fewer infections. Although this work does not establish a clear cause-and-effect relationship between safety culture and patient outcomes, it suggests that efforts to enhance safety culture could improve patient outcomes.
Govindarajan A, Urbach DR, Kumar M, et al. N Engl J Med. 2015;373:845-53.
The link between lack of sleep and subsequent medical errors served as an impetus for physician duty-hours reform. In trainee physicians, sleep loss is associated with attentional failures, but little is known about the relationship between attending physician performance and sleep loss. This retrospective cohort study examined outcomes of elective surgical procedures among attending surgeons who had worked after midnight on the previous night versus those who had not. The investigators found no differences in mortality, complications, or readmissions between procedures performed by surgeons with sleep loss compared to those without sleep loss, mirroring results of an earlier simulation study. This may be due to greater technical skill among attending surgeons, or the ability to cancel or postpone elective procedures as needed at times of fatigue. This study included many institutions, physicians, and procedure types, suggesting that short-term sleep deprivation might not be a high-yield safety target for attending surgeons.
Haut ER, Lau BD, Kraus PS, et al. JAMA Surg. 2015;150:912-5.
Prevention of hospital-acquired venous thromboembolism (VTE) is a strongly recommended patient safety practice. This retrospective review of hospital-acquired VTE at one tertiary care hospital found that many patients who developed VTE while hospitalized were prescribed appropriate prophylaxis but did not receive all of the prescribed doses. The authors point out that since current quality metrics measure only prescription of VTE prophylaxis and not actual administration, they may overestimate hospital performance on this safety issue. Moreover, nearly half of the patients with VTE had received prophylaxis that is currently considered optimal, an important finding since VTE is often referred to as a "preventable adverse event."
Thiels CA, Lal TM, Nienow JM, et al. Surgery. 2015;158:515-21.
Never events are devastating and preventable, and health care organizations are under increasing pressure to eliminate them completely. In this study, investigators evaluated all procedural never events using a validated human factors analysis method. They uncovered multiple underlying causes for each event. Cognitive failures were identified in about half the events. Preconditions, including environmental and technologic factors, were common contributors to events. Consistent with prior studies, the authors recommend enhancing communication among team members to augment safety. These results demonstrate the need to develop individual cognitive training interventions as well as systems approaches to address never events.
Osborne NH, Nicholas LH, Ryan AM, et al. JAMA. 2015;313:496-504.
This large study used 9 years of national fee-for-service Medicare data to examine differences in surgical outcomes between hospitals participating in the National Surgical Quality Improvement Program (NSQIP) and nonparticipating hospitals. There was no statistically significant difference in the rate of improvement for any of the measured outcomes—risk-adjusted 30-day mortality, serious complications, reoperation, or 30-day readmissions—at 1, 2, or 3 years after enrollment in NSQIP versus well-matched controls. Notably, over 6 years there has been a trend toward reductions in mortality, serious complications, and readmissions across hospitals, regardless of NSQIP participation. The results of this study strengthen those of the study by Etzioni and colleagues in the same issue of the Journal of the American Medical Association. In an accompanying editorial, Dr. Donald Berwick states, "it is implausible to conclude that knowing results is not useful—perhaps essential—for systematic improvement of outcomes," but that hospitals must realize measurement alone is insufficient.
Merkow RP, Ju MH, Chung JW, et al. JAMA. 2015;313:483-495.
Hospital readmissions have received intensive focus lately, largely compelled by Medicare's expanded financial penalties for excessive readmission rates. This study reviewed 30-day readmissions following surgery at hospitals enrolled in the National Surgical Quality Improvement Program. Nearly half a million operations were included, with an overall readmission rate of 5.7%. Following lower extremity vascular bypass, approximately 1 in 7 patients were readmitted. Surgical site infections accounted for the largest proportion of overall readmissions. It is notable that only 2% of patients were readmitted for the same complication that prompted their index admission, further confirming that surgical readmissions are overwhelmingly due to new complications arising from the procedure. In an accompanying editorial, Dr. Lucian Leape notes that analyses of these surgical complications can serve as "treasures" for providing important lessons for improvement, and he calls for a 50% reduction in surgical complication rates in the near term.
Reames BN, Krell RW, Campbell D, et al. JAMA Surg. 2015;150:208-15.
Initial enthusiasm for the role of checklists in reducing perioperative complications has been tempered by subsequent studies that did not replicate the safety improvements. This study evaluated the effect of the Keystone Surgery program, which combined an evidence-based checklist and the comprehensive unit-based safety program to enhance safety culture. Comparison of Keystone Surgery hospitals to those that did not implement the intervention found no differences in outcomes (including surgical site infections and 30-day mortality) between groups. The investigators acknowledge that many participating sites lacked the infrastructure to collect and regularly feed back performance data to frontline providers, which may have limited the effectiveness of the intervention. The study adds to a growing body of literature that emphasizes the role of effective implementation and monitoring in ensuring the success of checklist-based interventions. A PSNet interview and perspective explore the development and use of checklists to augment safety in health care.
Patel MS, Volpp KG, Small DS, et al. JAMA. 2014;312:2364-73.
This observational study sought to determine whether the ACGME 2011 duty hour reforms led to changes in 30-day mortality or readmissions for several medical diagnoses—acute myocardial infarction, stroke, acute gastrointestinal bleed, or congestive heart failure—and for general, orthopedic, or vascular surgery. The authors examined how hospital teaching status, which they defined using resident-to-bed ratio, affected outcomes for these conditions. This measure provides insight into the intensity of teaching at a given institution rather than defining each hospital as teaching versus nonteaching. During the study time period, although readmissions and mortality both declined overall, this decrease did not differ based on teaching status, suggesting that the improvement in readmissions and 30-day mortality is not attributable to duty hour reform. These results are consistent with prior work following the 2003 duty hour reforms which has failed to demonstrate benefit to patient outcomes from costly duty hour reforms. An editorial discussing this work and a companion study urge flexibility in duty hours for physicians in training.
Rajaram R, Chung JW, Jones AT, et al. JAMA. 2014;312:2374-84.
This observational study analyzed surgical outcomes before and after 2011 ACGME duty hours reform using data from the American College of Surgeons National Surgical Quality Improvement Program. Researchers applied difference-in-differences analysis, which can account for some of the uncertainty of nonrandomized data, a common concern in patient safety research. They assessed changes in surgical mortality and complication rates before and after implementation of duty hours restrictions in teaching hospitals. The authors compared this difference with mortality and complication rates during the same time period in nonteaching hospitals. Any variation between teaching and nonteaching sites could be attributed to the effects of duty hours, since the authors accounted for case mix and comorbidities. No differences in patient outcomes were observed, adding to the evidence that duty hours restrictions do not improve patient outcomes. Researchers also found no change in trainee examination scores, despite concerns that duty hours adversely impact trainee education. An editorial discussing this work and a companion study urge flexibility in duty hours for physicians in training.