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 144 Results

Sentinel Event Alert 68: Updated surgical fire prevention for the 21st Century.

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Jt Comm J Qual Patient Saf. 2023;Epub Oct 18.

Surgical fires are a rare yet potentially harmful event for both patients and care teams. The alert provides reduction guidance for organizations to mitigate conditions that enable surgical fires and suggests tactics to improve communication as a primary strategy for preventing this potentially catastrophic accident in operating rooms.

Unstoppable: this doctor has been investigated at every level of government. How is he still practicing?

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Waldman A. ProPublica. August 9, 2023

Systemic failures can enable poor practice to perpetuate without regard to safety. This news feature reports on systemic flaws that enabled a vascular surgeon with questionable business and clinical skills to continue to practice after numerous regulatory organizations investigated his clinics, and after patients reported harm.

Guidelines on Human Factors in Critical Situations 2023.

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Bijok B, Jaulin F, Picard J, et al. Anaesth Crit Care Pain Med. 2023;42:101262.

Human factors influence how humans and systems interact to make processes more reliable or more error-prone during both normal and unexpected circumstances. This guideline provides recommendations centered on elements of communication, the organization, the work environment, and training to guide the consideration of human factors in improvement actions during critical anesthesia or intensive care situations.

‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care.

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Gammon K. STAT. June 26, 2023.

The maternal mental health crisis results in harm to mothers and their families. This article discusses systemic issues that impact the safe psychological care of mothers from pregnancy through the years of caring for toddlers. Lack of timely diagnosis is a major consideration discussed.

Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN.

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Gillispie-Bell V. USA Today. April 14, 2023.

Structural racism and implicit biases can lead to poor quality of care and adverse outcomes among Black women. This article describes the experience of a Black OB/GYN patient whose concerns about abdominal pain during her pregnancy were not thoroughly evaluated; clinicians also missed risk factors placing her at risk of spontaneous preterm birth.

Hospital ‘black boxes’ put surgical practices under the microscope.

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Sadick B. Wall Street Journal. March 19, 2023.

Safety information systems that track action in real time can reveal a trove of data about how teams and procedures progress. This news article describes the use of a black-box system in the operating room. Its use by hospitals in the United States is described to illustrate the value of black box data to inform learning and improvement strategies.

Crowding in the Emergency Department: Challenges for the Care of Children.

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Gross TK, Lane NE, Timm NL, et al. Pediatrics. 2023;151:e2022060971-e2022060972.

Emergency room crowding is a persistent factor that degrades safety for patients of all ages. This collection provides background, best practices, and recommendations to reduce emergency department crowding and its negative impact on pediatric care. The publications examine factors that influence crowding and improvement at the input, departmental, and hospital/outpatient stages of emergency care.

Artificial intelligence, patient safety, and achieving the quintuple aim in anesthesiology.

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Tan JM, Cannesson MP. APSF Newsletter. 2023;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.

National Safety Standards for Invasive Procedures (NatSSIPs2).

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Centre for Perioperative Care. London, UK; January 2023.

Patients face risks when undergoing surgery. This revised guidance provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures. The report is centered on areas of effort targeting both organizational and process-level actions.

ER doctors misdiagnose patients with unusual symptoms.

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Abelson R. New York Times. December 15, 2022.

Emergency department safety is challenged by factors such as production pressure, burnout, and overcrowding. This news article provides context for the 2022 AHRQ report Diagnostic Errors in the Emergency Department: A Systematic Review from the Johns Hopkins Medicine Evidence-based Practice Center (EPC) which synthesized the number of patients harmed while seeking emergency care.

Jake Tapper shares harrowing story of daughter's near-fatal misdiagnosis.

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CNN. December 15, 2022.

Diagnostic errors are a recognized cause of preventable patient harm. This video highlights a teen’s misdiagnosed appendicitis and discusses factors associated with the error including lack of concern by staff for her pain and premature closure.

Safety of anesthetic and perioperative medication practices.

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Meyer TA. Anesthesiology News. October 31, 2022.

Medication use in the surgical environment is complex and high-risk. This article describes steps toward the implementation of medication safety process improvement programs for the operating room. Important steps discussed include assessment, analysis, planning, and implementation.

Curated Libraries

Diagnostic Safety

October 10, 2022

Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.

ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings.

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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.

A System in Need of Repair: Addressing Organizational Failures of the U.S.’s Organ Procurement and Transplantation Network.

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US Senate Finance Committee. 117th Cong (2021-2022). August 3, 2022.

Organ transplantation processes require reliable communication and technical expertise to ensure safety for organ delivery and patient care. This hearing discussed the findings of a United States Senate investigation into waste and harm in the US organ transplant system. Blood-type mistakes, transport failures, and process challenges were amongst the problems discussed.

Society for Maternal-Fetal Medicine Special Statement: cognitive bias and medical error in obstetrics-challenges and opportunities.

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Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:b2-b10.

The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.

APSF endorsed statement on revising recommendations for patient monitoring during anesthesia.

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The APSF Committee on Technology. APSF Newsletter. 2022;37(1):7–8.

Variation across standards and processes can result in misunderstandings that disrupt care safety. This guidance applied expert consensus to examine existing anesthesia monitoring standards worldwide. Recommendations are provided for organizations and providers to guide anesthesia practice in a variety of environments to address patient safety issues including accidental patient awareness during surgery.

Guideline for Prevention of Unintentionally Retained Surgical Items.

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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.

Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery.

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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

Maternal Safety

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.

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