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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 - 20 of 1698 Results

Järvinen TLN, Rickert J, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.
Bates DW, Levine DM, Salmasian H, et al. New Engl J Med. 2023;388:142-153.
An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher.
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.

Harolds JA, Harolds LB. Clin Nucl Med. 2015–2023.

This monthly commentary explores a wide range of subjects associated with patient safety, such as infection prevention, surgical quality improvement, and high reliability organizations.
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.
Oura P, Sajantila A. J Public Health Res. 2022;11:227990362211399.
Although patient safety is a national priority, preventable harm among patients remains high. After analyzing national death certificate data from 1999 through 2019, researchers in this study found that medical adverse events were listed as the underlying cause of death in 0.24% of deaths. From 2014 to 2019, researchers identified a nearly 16% annual increase in deaths attributed to adverse events, primarily driven by procedure-related adverse events and possibly related to the implementation of ICD-10 in 2015.
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.

WebM&M Case December 14, 2022

A 63-year-old woman was admitted to a hospital for anterior cervical discectomy (levels C4-C7) and plating for cervical spinal stenosis under general anesthesia. The operation was uneventful and intraoperative neuromonitoring was used to help prevent spinal cord and peripheral nerve injury. During extubation after surgery, the anesthesia care provider noticed a large (approximately 4-5 cm) laceration on the underside of the patient’s tongue, with an associated hematoma.

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.  

Arna D, ed. Curr Opin Anaesthesiol. 2022;35(6):710-737.

Safety challenges in anesthesiology and perioperative care are high-risk situations. This segment of a reoccurring special section covers strategies for improvement such as use of databases to monitor safety, expansion of safety improvement efforts to perioperative care, and cognitive aid use enhancement.
Carmack A, Valleru J, Randall KH, et al. Jt Comm J Qual Patient Saf. 2023;49:3-13.
Retained surgical items (RSI) are a never event, a serious and preventable event. After experiencing a high rate of RSIs, this United States health system implemented a bundle to reduce RSI, improve near-miss reporting, and increase process reliability in operating rooms. The bundle consisted of five elements: surgical stop, surgical debrief, visual counters, imaging, and reporting.

Meyer TA. Anesthesiology News. October 31, 2022.

Medication use in the surgical environment is complex and high-risk. This article describes steps toward the implementation of medication safety process improvement programs for the operating room. Important steps discussed include assessment, analysis, planning, and implementation.
Lentz CM, De Lind Van Wijngaarden RAF, Willeboordse F, et al. Int J Qual Health Care. 2022;34:mzac078.
Effective teamwork training for surgical teams can improve post-operative mortality rates. This review aimed to evaluate the effect of a dedicated surgical team (e.g., a team who received technical and/or communication teamwork training) on clinical and performance outcomes. Implementation of dedicated surgical teams resulted in improved mortality rates, but no difference in readmission rates or length of stay.
WebM&M Case November 16, 2022

A 58-year-old man underwent a complex surgery to replace his aortic valve. The surgery required prolonged cardiopulmonary bypass time and cross-clamp time and there was a short delay in redosing the cardioplegic solution and the patient developed “stone heart” due to suspected ischemic injury and was unable to come off bypass. The patient was placed on extracorporeal membrane oxygenation (ECMO) and transported to the ICU to allow family members to see the patient before stopping life support.

Ibrahim M, Szeto WY, Gutsche J, et al. Ann Thorac Surg. 2022;114:626-635.
Reports of poor care in the media or public reporting systems can serve as an impetus to overhauling hospitals or hospital units. After several unexpected deaths and a drop in several rating systems, this cardiac surgery department launched a comprehensive quality improvement review. This paper describes the major changes made in the department, including role clarity and minimizing variation in 24/7 staffing.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders. 
Lusk C, Catchpole K, Neyens DM, et al. Appl Ergon. 2022;104:103831.
Tall Man lettering and color-coding of medication syringes provide visual cues to decrease medication ordering and administration errors. In this study, an icon was added to the standard medication label; participants were asked to identify four medications, with and without the icon, from pre-defined distances. Participants correctly identified the medications with icons slightly more often.
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.