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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 - 14 of 14 Results
St Paul, MN: Minnesota Department of Health.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. June 2, 2020.

Neuromuscular blocking agents are high alert medications that can severely harm patients if used incorrectly. This announcement alerts clinicians to the absence of warning statements on two types of paralyzing agents, as well as to steps to minimize mistaken use.
de Lima A, Osman BM, Shapiro FE. Curr Opin Anaesthesiol. 2019;32.
Office-based anesthesia (OBA) is being performed more commonly internationally. This narrative literature review updates the evidence related to the safety of OBA and makes recommendations for safe practices including; medical directors to be responsible for evidence-based policies, OBA safety and patient checklists emergency procedures, physical setting requirements, pharmacological management, preoperative procedures, airway management and others. The authors identify that lack of consistent regulations and incomplete protocol standardization is problematic.
London, UK: Royal College of Surgeons of England; 2019.
Introducing innovations in practice involves taking calculated risks. To ensure patient safety, new techniques should be accompanied by training, oversight, and heightened awareness of the learning curve. This book provides a framework to guide the design and introduction of new surgical procedures into regular practice. It includes recommendations for auditing, cost assessment, and effectiveness review.
Stanisce L, Ahmad N, Deckard N, et al. Otolaryngol Head Neck Surg. 2019;160:1003-1008.
This pre–post study found that implementation of relative value unit–based payment in a head and neck surgery practice resulted in a higher volume of procedures. The incidence of adverse outcomes, including postoperative hospitalizations, infections, unplanned return surgeries, and emergency department visits, did not change. The authors conclude that the change in payment structure did not impact surgical safety.

Geneva: World Health Organization; 2018. ISBN-13: 978-92-4-155047-5.

Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence. The second edition of the Guidelines was released in 2018.
Urman RD, Punwani N, Shapiro FE. Curr Opin Anaesthesiol. 2012;25:648-53.
This narrative review explores how the practice of office-based anesthesia has increased and discusses the need for uniform regulations and accreditation to improve patient outcomes.
Perspective on Safety May 1, 2006
Over the last decade, surgical operations and interventional procedures have been performed increasingly in offices with the administration of office-based anesthesia (OBA).(1) Economic considerations and convenience have driven this increase. Schultz...
WebM&M Case March 1, 2006
A man undergoes plastic surgery at an outpatient center and winds up with a complication requiring prolonged stay in the ICU.