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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
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146:1235-9.
This analysis of incorrect surgical procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site, wrong-patient, and wrong-procedure errors compared with the authors' prior study. As in the earlier report, half of the incorrect procedures occurred outside of the operating room. Root cause analyses of errors revealed that lack of standardization and human factors issues were major contributing factors. During the time period of this study, the VA implemented a teamwork training program that has been associated with a significant decline in surgical mortality. The authors propose that additional, focused team training may be one solution to this persistent problem.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-34.
Wrong-patient and wrong-site surgeries are considered never events, as they are devastating errors that arise from serious underlying safety problems. This study used Veterans Administration data to analyze the broader concept of "incorrect" surgical procedures, including near misses and errors in procedures performed outside the operating room (for example, in interventional radiology). Root cause analysis was used to identify underlying safety problems. Errors occurred in virtually all specialties that perform procedures. The authors found that many cases could be attributed in part to poor communication that may not have been addressed by preoperative time-outs; for example, several cases in which surgical implants were unavailable would have required communication well before the day of surgery. The authors argue for teamwork training based on crew resource management principles to address these serious errors.
WebM&M Case August 21, 2007
A patient underwent tooth extraction, but awoke from anesthesia and found that the wrong two teeth had been removed.
Association of periOperative Registered Nurses.
This Web site includes information and resources for National Time Out Day, an initiative to raise awareness on the importance of surgical team time outs. The annual observation is in June.
Waterman AD, Gallagher TH, Garbutt J, et al. J Gen Intern Med. 2006;21:367-70.
This AHRQ–funded study used more than 2000 telephone interviews with recently discharged patients to demonstrate that patients who are most comfortable with error prevention were more likely to take specific action compared to those who are less comfortable. The authors report that although the majority of patients expressed comfort in asking questions about medications and general medical questions, far fewer actively engaged in marking their incision site or asking about handwashing. A past study discussed how to improve patients' perceptions of safety in hospitals, including educational interventions that might empower patients to take greater preventive action, as outlined in this study.
Kwaan MR, Studdert DM, Zinner MJ, et al. Arch Surg. 2006;141:353-7; discussion 357-8.
This AHRQ-supported study analyzed information from nearly 3 million operations between 1985 and 2004, discovering a rate of 1 in 112,994 cases of wrong-site surgery. Investigators further evaluated cases with available medical records, all of which were among the malpractice claims. In doing so, they noted that the Joint Commission's Universal Protocol might have prevented only 62% of the cases reviewed. At the rates reported, the authors suggest that the average large hospital may be involved in such an event every 5 to 10 years, a rate 10 times less frequent than retained foreign bodies. They also point out that while wrong-site surgery is a devastating and unacceptable outcome, current efforts to implement protocols may not prevent every event and may, in turn, create inefficiency in related processes. The authors offer a series of recommendations for a model site-verification protocol. The American College of Surgeons offers a fact sheet on correct-site surgery geared toward patient education.
WebM&M Case December 1, 2004
Despite a "time out" and having his leg marked by the surgeon, a patient comes perilously close to having surgery on the wrong leg.
WebM&M Case February 1, 2004
Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side.
WebM&M Case January 1, 2004
During a hernia repair, surgeons decide to remove a patient's hydrocele, spermatic cord, and left testicle—without realizing that his right testicle had been removed previously.