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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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Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144(6):536-541.

Patient safety in trauma poses unique challenges given the acuity of the patients and the need for rapid assessment in delivering life-saving care. This study analyzed more than 2500 complications discussed at morbidity and mortality (M&M) conferences to characterize their preventability and clinical relevance. Investigators discovered that the complications ripe for quality improvement initiatives included unintended extubations, surgical technical failures, missed injuries, and intravascular catheter-related complications. An invited critique [see link below] reflects on the study's findings and points out the challenges in reporting performance data without needed standardization. A past AHRQ WebM&M commentary discussed the systematic assessment of trauma patients in the context of a missed patient injury.