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.
This retrospective study of dental patient safety reports in the military health system demonstrated an increase in reported events, which may reflect improvements in safety culture. Wrong-site surgery was the most common adverse event, suggesting the need to enhance safety practices in dentistry.
Anoushiravani AA, Sayeed Z, El-Othmani MM, et al. Orthop Clin North Am. 2016;47:689-95.
High reliability organizations have developed methods for achieving safety despite hazardous conditions. This review explores the importance of establishing a culture of safety and leadership commitment to achieve high reliability in health care. The authors discuss the benefits of applying high reliability principles in orthopedic practice to standardize approaches and prevent wrong-site surgery.
James MA, Seiler JG, Harrast JJ, et al. J Bone Joint Surg Am. 2012;94:e2(1-12).
This study found that wrong-site surgeries continued to occur despite adoption of "Sign Your Site" initiatives and implementation of a Universal Protocol. The most common errors reported were related to wrong-level spine surgery.
This newspaper article discusses wrong-site surgeries and explores why the number of reported errors has not changed despite adoption of the Universal Protocol and other safety policies.
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.
National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194.
This report resulted from a consensus program involving 28 national organizations that sought to outline goals for improving the US health care system and share examples of such efforts in patient safety and other identified areas.
This article describes how the culture around medical errors is evolving to include disclosure and transparency, illustrated by a physician's willingness to discuss a wrong-site surgery.
This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results of other studies, and provides suggestions to reduce this type of error.
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
This article discusses how hospital design, including standardized operating rooms, better ventilation systems, and green design can improve patient safety and decrease costs.
This article reports the announcement of an international initiative to share patient safety strategies. The initiative will be led by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).