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
Narrow Results By
PSNet Original Content
Displaying 1 - 4 of 4 Results

Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.
Graham C, Reid S, Lord TC, et al. Br Dent J. 2019;226:32-38.
Reporting and avoidance of “never events,” such as a wrong tooth extraction, is important for providing consistently safe dental care. This article describes changes made in safety procedures, including introducing surgical safety briefings or huddles in an outpatient oral surgery unit of the United Kingdom’s National Health Service, that eliminated never events for more than two years.
Frey B, Ersch J, Bernet V, et al. Qual Saf Health Care. 2009;18:446-9.
Parents of hospitalized children feel personally responsible for their children's safety, and efforts are being made to engage parents in safety efforts. This retrospective review of incident reports found more than 100 cases in a 5-year period in which parents were directly involved in adverse events in a pediatric intensive care unit. These included cases where parents detected an adverse event as well as cases where the parents caused the adverse event (for example, by accidentally disconnecting equipment). The authors advocate for development of a safety culture that encourages parents to report concerns, a goal that is a major focus of the Josie King Foundation.
Garnerin P, Arès M, Huchet A, et al. Qual Saf Health Care. 2008;17:454-8.
This study combined implementation of verification protocols with periodic audits and feedback to increase compliance with patient identification in the prevention of wrong-patient and wrong-site surgery. While the process did improve, the authors advocate for technological solutions to address the limitations of purely manual systems. A related commentary [see link below] discusses the broader context of efforts to eliminate wrong-site surgery.