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 40 Results

HSIB Maternity Investigation Programme Year in Review 2021/22. Summary of Highlights, Themes and Future Work.

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Farnborough, UK: Healthcare Safety Investigation Branch; 2022. HSIB Report no. NI-005831

This report summarizes the work of an independent office that examines maternity care safety lapses in the United Kingdom. It discusses the number of investigations done, criteria for investigation selection and primary improvement themes drawn from the review of 706 investigations in the period covered which include clinical assessment and oversight, care escalation, and fetal monitoring. The report outlines the goal to establish a maternity review effort as an independent entity in 2023.

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.

Decontamination of Surgical Instruments.

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Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022.

Surgical equipment sterilization can be hampered by equipment design, production pressures, process complexity and policy misalignment. This report examines a case of unclean surgical instrument use. It recommends external sterile service assessment and competency review as steps toward improving the reliability of instrument decontamination processes in the National Health Service.

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.

CLER Report of Findings 2021: Subprotocol for Operative and Procedural Areas.

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Kuhn CM, Newton RC, Damewood MD, et al, on behalf of the CLER Evaluation Committee, the CLER Operative and Procedural Subprotocol National Advisory Group, and the CLER Program. Chicago, IL: Accreditation Council for Graduate Medical Education; February 2021. ISBN: 9781945365386.

The teaching hospital environment can produce clinician behaviors and mindsets that persist throughout a medical career. This report from a clinical learning environment assessment program shares insights gathered during walking rounds specific to perioperative care and general medicine. The report concluded that residents did not actively report problems and rarely participated in event investigations.

Each Baby Counts.

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Royal College of Obstetricians and Gynaecologists.

This organization highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm. The reporting initiative closed in 2021 after presenting its final report. Investigations in this area will now be undertaken by the Healthcare Safety Investigation Branch in England.

Serious Reportable Events in Massachusetts.

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Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2020.

This reoccurring report compiles patient safety data documented by Massachusetts hospitals. The 2019 numbers represent a modest increase in serious reportable events recorded in acute care hospitals, from 1066 the previous year to 1189. This presentation also includes events from ambulatory surgery centers. Older reports are also available.

Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust.

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NHS Improvement. Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust. NHS England. March 2020.

In-depth incident investigations provide details of care process examinations to motivate learning and improvement. This report examines cardiac surgery patient mortality at a National Health Service Trust over a 5-year period. It highlights weakness in professionalism at the individual and organization level as a contributor to the preventable patient deaths catalogued over that time.

Safety in Numbers: Hospital Performance on Leapfrog’s Surgical Volume Standard Based on Results of the 2019 Leapfrog Hospital Survey.

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Washington DC: Leapfrog Group; 2020.

Surgical volume standards are a metric used to assess the needed experience in performing distinct types of procedures. This report analyzed data from over 2,100 hospitals and found approximately half to be deficient in fully adhering to the standards while implementing mechanisms to minimize unnecessary surgeries

Checking In on the Checklist.

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Buissonniere M. Brooklyn NY: Lifebox and Ariadne Labs; 2020.

Checklists are integrated into error reduction strategies and healthcare team communication efforts worldwide but implementation and impact of the tool varies widely. This report examines the use of the WHO Surgical Safety Checklist and barriers to its uptake which include lack of effective staff introduction to the content, misperceptions about the time needed to use the tool and ineffective local contextualization of the content and process.

Investigation into Detection of Retained Vaginal Swabs and Tampons Following Childbirth.

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Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.

Maternal care during and after childbirth is at risk for never events including retained foreign objects. This analysis of a sentinel event involving a retained surgical tampon after childbirth discusses communication, fatigue, and process factors that contributed to the incident. The report suggests improved handoffs as one improvement strategy.

Quality and Safety in Anesthesia and Perioperative Care.

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Ruskin KJ, Stiegler MP, Rosenbaum SH, eds. New York, NY: Oxford University Press; 2016. ISBN: 9780199366149.

The perioperative setting is a high-risk environment. This publication discusses the clinical foundations and application of safety concepts in perioperative practice. Chapters cover topics such as human factors, error management, cognitive aids, safety culture, and teamwork.

Surgical Innovation, New Techniques and Technologies: A Guide to Good Practice.

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London, UK: Royal College of Surgeons of England; 2019.

Introducing innovations in practice involves taking calculated risks. To ensure patient safety, new techniques should be accompanied by training, oversight, and heightened awareness of the learning curve. This book provides a framework to guide the design and introduction of new surgical procedures into regular practice. It includes recommendations for auditing, cost assessment, and effectiveness review.

Learning From Invited Reviews.

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London, UK: Royal College of Surgeons of England; 2019.

Physical demands and technical complexities can affect surgical safety. This resource is designed to capture frontline perceptions of surgeons in the United Kingdom regarding concerning behaviors exhibited by their peers during practice to facilitate awareness of problems, motivate improvement, and enable learning.

AHRQ Safety Program for Surgery.

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Rockville, MD: Agency for Healthcare Research and Quality. December 2017. AHRQ Publication No. 16(18)-0004-1-EF.

Large-scale collaboratives have achieved success in implementing patient safety improvements. This report describes the work and outcomes of a 3-year surgical safety program funded by AHRQ that involved more than 200 hospitals in the United States. The project employed models and tools to implement surgical site infection prevention strategies. Participants reported substantial reductions of surgical site infections in their facilities.

Toolkit to Promote Safe Surgery.

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Rockville, MD: Agency for Healthcare Research and Quality; November 2017.

Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on the success of the Comprehensive Unit-based Safety Program to initiate change. The tools represent practical strategies that helped members of a large-scale collaborative to identify areas of weakness, design improvements, and track the impact of the interventions.

Global Guidelines on the Prevention of Surgical Site Infection.

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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.

Surgical Patient Safety: A Case-Based Approach.

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Stahel PF, ed. New York, NY: McGraw-Hill Education/Medical; 2017. ISBN: 9780071842631.

Surgical residency can be a stressful learning experience. This textbook provides an introduction to nontechnical aspects of safe surgical practice, a collection of case studies that illustrate technical challenges in the operating room, and insights regarding other elements of health care that can affect the safety of surgical care, such as health information technology.

Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety.

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Wiley K, Davies JM. Edmonton, AB: Canadian Patient Safety Institute; 2017.

Proactive analysis can help uncover process weaknesses and ensure improvements are implemented before patients experience harm. This guide provides insights for organizations who seek to implement proactive analysis strategies. Tools and models discussed include Reason's Swiss cheese model and Systems Engineering Initiative for Patient Safety.

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