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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 - 19 of 19 Results

Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.

Medication errors associated with surgery and other invasive procedures can result in patient harm. This 10-element guidance suggests effective practices to address identified weaknesses in perioperative and procedural medication processes. Recommendations provided cover topics such as drug labeling, communication, and risk management.
Croke L. AORN J. 2021;114:4-6.
Retained surgical items (RSI) are a never event, yet they continue to happen. This commentary summarizes recent changes to an existing guidance that defines a range of retained devices or products to coalesce with industry terminology. The author shares steps to reduce the potential for RSI retention. 
Combs CA, Einerson BD, Toner LE. Am J Obstet Gynecol. 2021;225:b43-b49.
Maternal and newborn safety is challenged during cesarean delivery due to the complexities of the practice. This guideline recommends specific checklist elements to direct coordination and communication between the two teams engaged in cesarean deliveries. The guideline provides a sample checklist and steps for its implementation.
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.
Bickham P, Golembiewski J, Meyer T, et al. Am J Health Syst Pharm. 2019;76:903-820.
Pharmacists working with surgical teams bring distinct safety context, expertise, and process awareness to perioperative care. These guidelines outline how pharmacists can help reduce medication errors before, during, and after surgery. Perioperative pharmacists can enhance communication, medication histories, and process reliability.
Rosengart TK, Doherty G, Higgins R, et al. JAMA Surg. 2019;154:647-653.
Potential deterioration of older surgeons' technical performance is a patient safety concern. This guidance developed from a Society of Surgical Chairs panel discussion puts forth several steps to manage the transition of aging surgeons. Recommendations include mandatory cognitive and psychomotor testing for surgeons age 65 and older, respectful consideration of the financial and emotional concerns of aging surgeons, and lifelong mentoring around the transition from clinical to nonclinical roles. The authors anticipate that such initiatives will prompt thoughtful support for aging surgeons that ensures patient safety. In an accompanying editorial, an older physician supports mandatory testing and suggests individual-level steps to address aging as a surgeon, including healthy lifestyle and financial habits.

Geneva: World Health Organization; 2018. ISBN-13: 978-92-4-155047-5.

Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence. The second edition of the Guidelines was released in 2018.
London, UK: Royal College of Surgeons of England; 2016.
Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides information for surgeons to help them identify individual and organizational biases and to address disrespectful behaviors through training and peer support mechanisms.

NHS England Patient Safety Domain, National Safety Standards for Invasive Procedures Group. London, UK: National Health Service; 2015.

Patients face risks when undergoing invasive procedures. This report provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures.
Artibani W, Ficarra V, Challacombe BJ, et al. Eur Urol. 2014;66:87-97.
The practice of live surgical procedures for educational purposes presents safety concerns for patients. This policy statement details organizational requirements and provides a checklist to help ensure that these events are conducted safely.
Commission J. Sentinel event alert. 2013:1-5.
Sentinel event alerts are issued periodically by The Joint Commission to identify common or emerging patient safety problems and provide organizations with approaches for addressing these issues. A retained foreign object (RFO)—surgical materials or equipment unintentionally left in a patient's body after completing the operation—is a never event that can have serious clinical consequences. Despite being long recognized as a critical—and preventable—error, RFOs continue to occur, with nearly 800 cases being reported to The Joint Commission between 2005 and 2012. This alert makes several recommendations to help prevent RFOs, including focusing on enhancing the reliability of the traditional manual count of instruments and materials used during a procedure, improving safety culture in the operating room through interventions (e.g., teamwork training), and investigating technological approaches (e.g., bar coding of surgical sponges) to ease identification of potentially missing objects before patients are harmed.
Wahr JA, Prager RL, Abernathy JH, et al. Circulation. 2013;128:1139-1169.
This scientific statement from the American Heart Association (AHA) reviews the current state of knowledge on safety issues in the operating room (OR) and provides detailed recommendations for hospitals to implement to improve safety and patient outcomes. These recommendations include using checklists and formal handoff protocols for every procedure, teamwork training and other approaches to enhance safety culture, applying human factors engineering principles to optimize OR design and minimize fatigue, and taking steps to discourage disruptive behavior by clinicians. AHA scientific statements, which are considered the standard of care for cardiac patients, have traditionally focused on clinical issues, but this article (and an earlier statement on medication error prevention) illustrates the critical importance of ensuring safety in this complex group of patients.
Chow WB, Rosenthal RA, Merkow RP, et al. J Am Coll Surg. 2012;215:453-66.
This guideline describes recommendations for preoperative assessment of elderly surgical patients, including risk factors for postoperative delirium and pulmonary complications, to enhance safety and reduce readmissions.
Improvement AC of O and GCC on PS and Q. Obstet Gynecol. 2009;114:1424-7.
In this piece, the American College of Obstetricians and Gynecologists emphasizes principles and objectives for patient safety in obstetrics and gynecology practices. The guidelines include encouraging a safety culture, reducing surgical errors, improving communication with patients and providers, and prioritizing safety.
JCAHO; Joint Commission on Accreditation of Healthcare Organizations.
According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.