Skip to main content

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.

Search All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
Displaying 1 - 20 of 213 Results
Seidelman JL, Mantyh CR, Anderson DJ. JAMA. 2023;329:244-252.
Surgical site infections (SSIs) remain a significant cause of preventable post-operative morbidity and mortality. This narrative review summarizes modifiable and nonmodifiable patient-related factors. It also evaluates modifiable operation-related factors associated with surgical site infections, and highlights six pre-, intra-, and postoperative strategies to reduce surgical site infections, including use of the WHO surgical safety checklist.
WebM&M Case February 1, 2023

These cases describe the rare but dangerous complication of hematoma following neck surgery. The first case involves a patient with a history of spinal stenosis who was admitted for elective cervical discectomy and cervical disc arthroplasty who went into cardiopulmonary arrest three days post-discharge and could not be intubated due to excessive airway swelling and could not be resuscitated. Autopsy revealed a large hematoma at the operative site, causing compression of the upper airway, which was the suspected cause of respiratory and cardiac arrest.

Sutton E, Booth L, Ibrahim M, et al. Qual Health Res. 2022;32:2078-2089.
Patient engagement and encouragement to speak up about their care can promote patient safety. This qualitative study explored patients’ psychosocial experiences after surviving abdominal surgery complications. Findings highlight an overarching theme of vulnerability and how power imbalances between patients and healthcare professionals can influence speaking up behaviors.
Varady NH, Worsham CM, Chen AF, et al. Proc Natl Acad Sci USA. 2022;119:e2210226119.
Safe prescribing dictates that prescriptions should only be written for the patients who are intended to use the prescribed medications. Using claims data, this analysis identified a high rate of opioid prescriptions written for and filled by the spouses of patients undergoing outpatient surgery (who may be unable to fill prescriptions themselves after surgery). Findings suggest intentional, clinically inappropriate prescribing of opioids.
WebM&M Case December 14, 2022

A 62-year-old Spanish-speaking woman presented to the pre-anesthesia area for elective removal of a left thigh lipoma. Expecting a relatively simple outpatient operation, the anesthesiologist opted not to use a Spanish language translator and performed a quick pre-anesthesia evaluation, obtaining her history from the medical record. Unknown to the anesthesiologist, the patient was trying to communicate to him that she had undergone jaw replacement surgery and that her mouth opening was therefore anatomically limited.

Marsh KM, Turrentine FE, Schenk WG, et al. Ann Surg. 2022;276:e347-e352.
The perioperative period represents a vulnerable time for patients. This retrospective review of patients undergoing surgery at one hospital over a one-year period concluded that medical errors (including, but not limited to, technical errors, diagnostic errors, system errors, and errors of omission) were strongly associated with postoperative morbidity.
Wani MM, Gilbert JHV, Mohammed CA, et al. J Patient Saf. 2022;18:e1150-e1159.
The WHO surgical safety checklist has been implemented in healthcare systems around the world. This scoping review identified five categories of barriers to successful implementation of the WHO checklist (organizational-, checklist-, technical-, and implementation barriers, as well as individual differences). The authors outline recommendations for researchers, hospital administrators, and operating room personnel to improve checklist implementation.  
WebM&M Case October 27, 2022

A 47-year-old man underwent a navigational bronchoscopy with transbronchial biospy under general anesthesia without complications. The patient was transferred to the post-acute care unit (PACU) for observation and a routine post-procedure chest x-ray (CXR). After the CXR was taken, the attending physician spoke to the patient and discussed his impressions, although he had not yet seen the CXR. He left the PACU without communicating with the bedside nurse, who was caring for other patients. The patient informed the nurse that the attending physician had no concerns.

WebM&M Case October 27, 2022

A 49-year-old woman presented to an Emergency Department (ED) with abdominal pain nine hours after discharge following outpatient laparoscopic left oophorectomy. The left oophorectomy procedure involved an umbilical port placed using an Optiport visual trocar, a suprapubic port, and two additional ports laterally.

Uramatsu M, Maeda H, Mishima S, et al. J Cardiothorac Surg. 2022;17:182.
Wrong-patient transfusion errors can lead to serious patient harm. This case report describes a blood transfusion error and summarizes the systems issues that emerged during the root case analysis, as well as the corrective steps implemented by the hospital to prevent future transfusion errors. A previous Spotlight Case featured a near-miss transfusion error and strategies for ensuring safe transfusion practices.
Stenquist DS, Yeung CM, Szapary HJ, et al. J Am Acad Orthop Surg Glob Res Rev. 2022;6:e22.00079.
The I-PASS structured handoff tool has been widely implemented to improve communication during handoffs and patient transfers. In this study, researchers modified the I-PASS tool for use in orthopedic surgery and assessed the impact on adverse clinical outcomes. After 18 months, there was sustained adherence to the tool and the quality of handoffs improved, but no notable changes in clinical outcomes were identified.
Wylie JA, Kong L, Barth RJ. Ann Surg. 2022;276:e192-e198.
“Opioid never event” (ONE) is a proposed classification to describe dependence or overdose among opioid-naïve patients prescribed opioids at hospital discharge. Based on a retrospective review of medical records of patients at one academic medical center, researchers estimated that the ONE affected approximately 2 per 1,000 opioid-naïve surgical patients and persistent opioid use 90 to 360 days after surgery was present in 45% of patients with ONEs.
Parker H, Frost J, Day J, et al. PLoS ONE. 2022;17:e0271454.
Prophylactic antimicrobials are frequently prescribed for surgical patients despite the risks of antimicrobial overuse (e.g., resistance). This review summarizes how and why antimicrobials continue to be prescribed in surgical settings despite evidence of overuse. Eight overarching concepts were identified: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment.
Uffman JC, Kim SS, Quan LN, et al. Pediatr Qual Saf. 2022;7:e574.
Pediatric patients are highly vulnerable to patient safety events in the hospital. This retrospective study of infants less than 6 months of age admitted for ambulatory surgery found that the recommended 2-hour postoperative monitoring did not affect patient safety.   

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.
Massart N, Mansour A, Ross JT, et al. J Thorac Cardiovasc Surg. 2022;163:2131-2140.e3.
Surgical site infections and other postoperative healthcare-acquired infections (HAIs) can lead to significant patient morbidity and mortality. This retrospective study examined the relationship between HAIs after cardiac surgery and postoperative inpatient mortality. Among 8,853 patients undergoing cardiac surgery in one academic hospital in France, 4.2% developed an HAI after surgery. When patients developing an HAI were matched with patients who did not, the inpatient mortality rate was significantly greater among patients with HAIs (15.4% vs. 5.7%).
Tham N, Fazio T, Johnson D, et al. World J Surg. 2022;46:1249-1258.
The COVID-19 pandemic led to changes in infection control and prevention measures to limit nosocomial spread. This retrospective cohort study found that escalations in infection prevention and control practices due to the COVID-19 pandemic did not affect the incidence of other hospital-acquired infections among surgical patients at one Australian hospital. The authors posit that this may be due to high compliance with existing infection prevention and control practices pre-pandemic.
Forrester JD, Maggio PM, Tennakoon L. J Patient Saf. 2022;18:e477-e479.
Healthcare-associated infections (HAIs) result in poorer patient outcomes and increased costs. The 2016 national data set of five common HAIs (surgical site infections, catheter- and line-associated bloodstream infections, catheter-associate urinary tract infections, ventilator-associated pneumonia, and Clostridioides difficile) was analyzed to create an estimated national cost. Clostridioides difficile was the most frequently reported; Clostridioides difficile and surgical site infections accounted for 79% of costs.
Pérez Zapata AI, Rodríguez Cuéllar E, de la Fuente Bartolomé M, et al. Patient Saf Surg. 2022;16:7.
Trigger tools are one method of retrospectively detecting adverse events. In this study, researchers used data from 31 Spanish hospitals to validate a trigger tool in general and gastrointestinal surgery departments. Of 40 triggers, 12 were identified for optimizing predictive power of the trigger tool, including broad spectrum antibiotherapy, unscheduled postoperative radiology, and reintervention.
Sun LY, Jones PM, Wijeysundera DN, et al. JAMA Netw Open. 2022;5:e2148161.
Previous research identified a relationship between anesthesia handoffs and rates of major complications and mortality compared to patients who had the same anesthesiologist throughout their procedure. This retrospective cohort study including over 102,000 patients in Ontario, Canada, explored this relationship among patients undergoing cardiac surgery. Analyses revealed that anesthesia handovers were associated with poorer outcomes (i.e., higher 30-day and one-year mortality rates, longer hospitalizations and intensive care unit stays) compared with patients who had the same anesthesiologist throughout their procedure.