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.
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, care standardization,teamwork, unit-based safety initiatives, and...
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.
This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.
Eager to have his knee replaced, an active older patient travels overseas for the surgery. At home 2 weeks later, he develops acute pain and swelling in his knee. A local orthopedic surgeon's office tells him to contact his operating physician, nearly 5000 miles away.
The Joint Commission has traditionally focused on accreditation of health care organizations and, through its Joint Commission Resources arm, on quality improvement (QI) in areas related to its accreditation functions. In the first major initiative under the leadership of new president Dr. Mark Chassin, The Joint Commission launched this Center, which will focus on applying rigorous QI methods to improve safety in a number of challenging areas (the first three are hand hygiene, handoff communication, and preventing wrong site surgery) and disseminating the lessons from these efforts. This Web site provides more information about the Center and its goals.
Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.
This government report analyzes the National Health Service's efforts to enhance patient safety and recommends improving certain areas, such as adopting technology, analyzing failure, and ensuring both practitioner education and adequate staffing.
Weinberg DB, Gittell JH, Lusenhop W, et al. Health Serv Res. 2007;42:7-24.
The investigators surveyed patients regarding the coordination of their postdischarge care and identified problems with coordination across settings, within settings, and between patients and providers.
Owing to privacy concerns, a nurse draws the drapes on a 3-year-old child in recovery following surgery, and unfortunately does not realize the child is in distress until loud inspiratory stridor is heard.
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