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 - 17 of 17 Results

Cognitive bias and dissonance in surgical practice: a narrative review.

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Richburg CE, Dossett LA, Hughes TM. Surg Clin North Am. 2023;103:271-285.

Cognitive biases can threaten patient safety in a variety of ways. This narrative review summarizes the common cognitive biases in surgical care and how they threaten patient safety, including delays in diagnosis and treatment, unnecessary surgeries, and intraoperative errors and complications. The authors also discuss cognitive debiasing strategies to mitigate the impact of cognitive biases.

Delayed Diagnosis of Kidney Transplant Complications

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WebM&M Case February 23, 2022

A 69-year-old man with End-Stage Kidney Disease (ESKD) secondary to diabetes mellitus and hypertension, who had been on dialysis since 2014, underwent deceased donor kidney transplant. The case demonstrates the complex nature of management of allograft dysfunction due to vascular complications in a patient with deceased donor kidney transplant in the early post-transplant period.

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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.

Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.

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WebM&M Case November 25, 2020

After a failed induction at 36 weeks, a 26-year-old woman underwent cesarean delivery which was complicated by significant postpartum hemorrhage. The next day, the patient complained of severe perineal and abdominal pain, which the obstetric team attributed to prolonged pushing during labor. The team was primarily concerned about hypotension, which was thought to be due to hypovolemia from peri-operative blood loss. After several hours, the patient was transferred to the medical intensive care unit (ICU) with persistent hypotension and severe abdominal and perineal pain. She underwent surge

Patient Safety.

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Halamek LP, ed. Semin Perinatol. 2019;43(8):151172-151182.

The neonatal intensive care unit (NICU) is a complex environment that serves a vulnerable population at increased risk for harm should errors occur. This special issue draws from a multidisciplinary set of authors to explore patient safety issues arising in the NICU. Included in the issue are articles examining topic such as video assessment, diagnostic error, and human factors engineering in the NICU.

Abdominal Aortic Aneurysm Screening

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WebM&M Case August 1, 2018

An older man with multiple medical conditions and an extensive smoking history was admitted to the hospital with worsening shortness of breath. He underwent transthoracic echocardiogram, which demonstrated severe aortic stenosis. The cardiology team recommended cardiac catheterization, but the interventional cardiologist could not advance the catheter and an aortogram revealed an abdominal aortic aneurysm (AAA) measuring 9 cm in diameter. Despite annual visits to his primary care physician, he had never undergone screening ultrasound to assess for presence of an AAA.

Patient Safety.

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Todd DW, Bennett JD, eds. Oral Maxillofac Surg Clin North Am. 2017;29:121-244.

Articles in this special issue provide insights into how human error can affect the safety of oral and maxillofacial surgery, a primarily ambulatory environment. The authors cover topics such as simulation training, wrong-site surgery, and the safety of office-based anesthesia.

Don't Dismiss the Dangerous: Obstetric Hemorrhage

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WebM&M Case November 1, 2016

After an emergency cesarean delivery, a woman had progressive tachycardia and persistent hypertension. A CT scan showed no evidence of pulmonary embolism, but repeat blood tests showed a dangerously low hemoglobin level and markedly elevated liver enzyme levels. She was taken back to the operating room and found to have postpartum hemorrhage.

Emergency Error

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WebM&M Case August 21, 2013

An elderly woman with severe abdominal pain was admitted for an emergency laparotomy for presumed small bowel obstruction. Shortly after induction of anesthesia, her heart stopped. She was resuscitated and transferred to the intensive care unit, where she died the next morning. The review committee felt this case represented a diagnostic error, which led to unnecessary surgery and a preventable death.

Automated identification of postoperative complications within an electronic medical record using natural language processing.

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Murff HJ, FitzHenry F, Matheny ME, et al. JAMA. 2011;306:848-55.

Many adverse event identification methods cannot detect errors until well after the event has occurred, as they rely on screening administrative data or review of the entire chart after discharge. Electronic medical records (EMRs) offer several potential patient safety advantages, such as decision support for averting medication or diagnostic errors. This study, conducted in the Veterans Affairs system, reports on the successful development of algorithms for screening clinicians' notes within EMRs to detect postoperative complications. The algorithms accurately identified a range of postoperative adverse events, with a lower false negative rate than the Patient Safety Indicators. As the accompanying editorial notes, these results extend the patient safety possibilities of EMRs to potentially allow for real time identification of adverse events.

Prevention of surgical malpractice claims by a surgical safety checklist.

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de Vries EN, Eikens-Jansen MP, Hamersma AM, et al. Ann Surg. 2011;253:624-8.

This retrospective claims record review found that nearly one-third of all contributing factors may have been mitigated by using the SURPASS surgical checklist.

"Recurrent" Appendicitis

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WebM&M Case October 1, 2010

Following an appendectomy, an elderly man continued to have right lower quadrant pain. Reviewing the specimen removed during the surgery, the pathologist found no appendiceal tissue. The patient was emergently taken back to the OR, and the appendix was located and removed.

Beeline to Spine

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WebM&M Case June 1, 2007

Based on preoperative discussions, a patient undergoing knee replacement expected to receive spinal anesthesia; however, general anesthesia was administered, and the records did not note or explain this change. The patient suffered an unusual complication.

Surgical accountability in the 1880s: the death of Susan Nixon.

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Watters GR, Walker DR. ANZ J Surg. 2005;75.

Using an account of surgical error from nineteenth-century Australia, the authors draw parallels with how medical mistakes and accountability are discussed today.

X-ray Flip

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WebM&M Case February 1, 2004

Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side.

Inadvertent Castration

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WebM&M Case January 1, 2004

During a hernia repair, surgeons decide to remove a patient's hydrocele, spermatic cord, and left testiclewithout realizing that his right testicle had been removed previously.

Did We Forget Something?

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WebM&M Case September 1, 2003

A patient dies from infection and complications months after surgery; a retained sponge is found at autopsy.

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