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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 40 Results
Am J Obstet Gynecol. 2023;Epub Feb 2.
Efforts to embed patient safety content into defined post-graduate medical curriculum face challenges due to time, culture, and program resource demands. This statement provides detailed safety and quality content recommendations for maternal-fetal medicine fellows that focus on topics such as safety culture, event reporting, and disparities.
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.
Kelly FE, Frerk C, Bailey CR, et al. Anaesthesia. 2023;Epub Jan 11.
Human factors engineering has the potential to mitigate failures by designing workspaces and processes to prevent errors from occurring. This guidance uses the hierarchy of controls framework to organize human-factors recommendations focusing on the design of anesthesia environments and equipment to infuse protections into care service.
Healy A, Davidson C, Allbert J, et al. Am J Obstet Gynecol. 2023;228:b8-b17.
The demand for, and acceptance of, telemedicine solutions to provide services has grown substantially in recent years as safety profiles for the services are being defined. This guideline examines its use in pregnancy-related care, discusses the benefits and suggests actions to ensure patient safety during these encounters such as development of appropriate metrics and methods for vital-sign monitoring.
Joseph MM, Mahajan P, Snow SK, et al. Pediatrics. 2022;150:e2022059673.
Children with emergent care needs are often cared for in complex situations that can diminish safety. This joint policy statement updates preceding recommendations to enhance the safety of care to children presenting at the emergency department. It expands on the application of topics within a high-reliability framework focusing on leadership, managerial factors, and organizational factors that support safety culture and workforce empowerment to support safe emergency care for children.
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.
Combs CA, Goffman D, Pettker CM. Am J Obstet Gynecol. 2022;226:b2-b9.
Readmission reduction as an improvement measure has been found to be problematic as a maternal safety outcome. This statement shares concerns regarding incentivizing hospitalization reductions after birth and explores the potential for patient harm due to pressures to reduce readmissions when needed.
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. 
Curated Libraries
January 14, 2022
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication 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.
Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. JAMA Surg. 2021;156:76.
Opioid misuse is an urgent patient safety issue, including postsurgical opioid misuse among pediatric patients. Based on the systematic review, a multidisciplinary group of health care and opioid stewardship experts proposes evidence-based opioid prescribing guidelines for children who need surgery. Endorsed guideline statements highlight three primary themes for perioperative pain management in children: (1) health care professionals must recognize the risks of pediatric opioid misuse, (2) use non-opioid pain relief, and (3) pre- and post-operative education for patients and families regarding pain management and safe opioid use.
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.
Lefebvre G, Calder LA, De Gorter R, et al. J Obstet Gynaecol Can. 2019;41:653-659.
Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. This commentary describes the importance of standardization, checklist use, auditing and feedback, peer coaching, and interdisciplinary communication as strategies to reduce risks. The discussion spotlights the need for national guidelines and definitions to reduce variation in auditing and training activities and calls for heightened engagement of health care professionals to improve the safety and quality of obstetric care in Canada. An Annual Perspective reviewed work on improving maternal safety.
Munoz-Price S, Bowdle A, Johnston L, et al. Infect Control Hosp Epidemiol. 2018:1-17.
This expert guidance provides recommendations to help health care facilities develop policies for preventing health care–associated infections in the operating room. The authors build on existing anesthesia safety practices to outline specific actions for infection prevention and control.
Remick K, Gausche-Hill M, Joseph MM, et al. Pediatrics. 2018;142.
This revised set of guidelines suggests standards to ensure high-quality care for pediatric patients in the emergency department, including a section on improving patient safety. Key recommendations focus on pediatric emergency care coordinators and implementing quality control mechanisms.
AORN J. 2018;108:64-65.
Categorizing human error as a criminal act can deter reporting required to learn from incidents and improve practice. This position statement articulates the importance of avoiding this approach for unintentional perioperative nursing errors to ensure the open communication needed to support the safety of clinicians, organizations, and patients.