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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 24 Results

Tan JM, Cannesson MP. APSF Newsletter2023;38(2):1,3–4,7.

Technological advancement is a hallmark of anesthesiology safety improvement. This article discusses the opportunities that artificial intelligence (AI) represents for anesthesiologists and provides a practical framework for understanding the important relationship to be optimized between AI and perioperative care to support patient safety.
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.
Feeley D, Torres T. Healthcare Executive. 2020;35:58-61.
A variety of biases can reduce the effectiveness and safety of care. This commentary focuses on racial bias and highlights its deleterious impact on maternity care and maternal safety. The authors suggest tactics to improve listening, implicit bias acknowledgement and data standardization as strategies to counteract the trend.
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.
Hilton K, Anderson A. Harv Bus Rev. May 20, 2019.
This commentary describes how one health system worked to combat resistance to change associated with implementation of a checklist initiative. The success of the program was built on empowering team members to drive the process, clinician motivation to provide safe care, and engaging leadership. A PSNet interview with Lucian Leape discussed surgical safety checklists.
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.
Bruley ME, Arnold TV, Finley E, Deutsch ES, Treadwell JR. PA-PSRS Pa Patient Saf Advis. June 2018;15.
Although surgical fires are considered never events, they continue to occur. This article reports findings from an analysis of 28 operating room fire incidents submitted over a 5-year period to the Pennsylvania Patient Safety Reporting System. Although incidence of surgical fires has significantly decreased since earlier reporting periods, half of the reported events resulted in patient harm. A past WebM&M commentary discussed surgical fires and how to prevent them.
Boodman SG. Kaiser Health News. July 12, 2017.
Scheduling overlapping surgeries has gained recognition as a controversial practice in surgical care. This news article reports on concurrent procedures, how double-booking can result in loss of trust in the surgical team, and motivations for the practice such as efficiency.
Rice S. Modern healthcare. 2016;46:14-6.
Although checklist implementation as a safety strategy has achieved some success, it has also faced scrutiny. This magazine article discusses a statewide checklist effort that tested a structured initiative for engaging hospitals in utilizing a pre-surgical checklist in their operating rooms.
Abelson J, Saltzman J, Kowalcyzk L, Allen S. Boston Globe. October 26, 2015.
Scheduling concurrent surgeries can have negative effects on staff and patients. This investigative news article explores the practice of overlapping procedures at a leading hospital, potential risks associated with double-booked cases, lack of transparency with patients involved, as well as the potential impact on patient safety.
Luthra S. Kaiser Health News. July 14, 2015.
Distractions can lead to care and process omissions. Reporting on the prevalence of mobile technology in the operating room and how it can hinder teamwork, this news article calls for guidance to regulate smartphone use in health care environments to enhance safety of care delivery.
Whitehead N. National Public Radio. June 18, 2015.
The competency of surgeons as they age has been debated as a risk to patient safety. This news article describes concerns about the aging population of surgeons in the United States and an American Medical Association effort to develop guidelines to assess skills of older physicians.
Sternberg S; Dougherty G.
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.
Clark C. HealthLeaders Media. July 24, 2014.
The Hospital Compare Web site has begun to publicly report which hospitals are using checklists, and the results are concerning. Investigating reasons behind these findings, this news piece offers insights from physicians into why checklists have not been universally implemented and highlights the importance of developing a culture of safety to drive improvement efforts.