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.
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.
Marsh KM, Turrentine FE, Knight K, et al. Ann Surg. 2022;275:1067-1073.
Having standardized definitions and classifications of errors allows researchers to better understand potential causes and interventions for improvement. This systematic review identified six broad error categories, 13 definitions of error, and 14 study methods in the surgical error literature. Development and use of a common definition and taxonomy of errors will provide a more accurate indication of the prevalence of surgical error rates.
Parker H, Frost J, Day J, et al. PLoS ONE. 2022;17:e0271454.
Prophylactic antimicrobials are frequently prescribed for surgical patients despite the risks of antimicrobial overuse (e.g., resistance). This review summarizes how and why antimicrobials continue to be prescribed in surgical settings despite evidence of overuse. Eight overarching concepts were identified: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment.
Marsh KM, Fleming MA, Turrentine FE, et al. J Pediatr Surg. 2022;57:616-621.
Patient safety improvement can be hindered by lack of effective measurement tools. This scoping review explored how medical errors are defined and measured in studies of pediatric surgery patients. The authors identified several evidence gaps, including absence of standardized error definitions.
Locey KJ, Webb TA, Stein BD, et al. Jt Comm J Qual Patient Saf. 2022;48:403-410.
The AHRQ patient safety indicators (PSIs) are widely used measures of preventable complications and quality of care. This study found that a hospital’s internal policies about admission type introduces variation in PSI scores for elective surgeries.
Krenzischek DA, Card E, Mamaril M, et al. J Perianesth Nurs. 2022;37:827-833.
Patients and caregivers are important partners in promoting safe care. Findings from this cross-sectional study reinforce the importance of patients’ perceived roles in ensuring safe surgery and highlight the importance of patient engagement in mitigating surgical site errors.
Armstrong BA, Dutescu IA, Nemoy L, et al. BMJ Qual Saf. 2022;31:463-478.
Despite widespread use of surgical safety checklists (SSC), its success in improving patient outcomes remains inconsistent, potentially due to variations in implementation and completion methods. This systematic review sought to identify how many studies describe the ways in which the SSC was implemented and completed, and the impact on provider outcomes, patient outcomes, and moderating factors. A clearer positive relationship was seen for provider outcomes (e.g., communication) than for patient outcomes (e.g., mortality).
Al-Ghunaim TA, Johnson J, Biyani CS, et al. Am J Surg. 2022;224:228-238.
Burnout in healthcare providers has been linked to lower patient safety and increased adverse events. This systematic review examined studies focusing on the relationship between burnout and patient safety and professionalism in surgeons. Results indicate higher rates of burnout and emotional exhaustion were associated with an increased risk of involvement in medical error. Interventions to reduce burnout and improve surgeon well-being may result in improved patient safety.
Dorken Gallastegi A, Mikdad S, Kapoen C, et al. J Surg Res. 2022;274:185-195.
While interoperative deaths (IODs) are rare, they are catastrophic events. This study analyzed five years of data on IODs from a large academic medical center. The authors describe three phenotypes: patients with traumatic injury, those undergoing non-trauma-related emergency surgery, and patients who die during an elective procedure from medical cardiac arrests or vascular injuries. This classification framework can serve as a foundation for future research or quality improvement processes.
Sun LY, Jones PM, Wijeysundera DN, et al. JAMA Netw Open. 2022;5:e2148161.
Previous research identified a relationship between anesthesia handoffs and rates of major complications and mortality compared to patients who had the same anesthesiologist throughout their procedure. This retrospective cohort study including over 102,000 patients in Ontario, Canada, explored this relationship among patients undergoing cardiac surgery. Analyses revealed that anesthesia handovers were associated with poorer outcomes (i.e., higher 30-day and one-year mortality rates, longer hospitalizations and intensive care unit stays) compared with patients who had the same anesthesiologist throughout their procedure.
Gillespie BM, Harbeck EL, Rattray M, et al. Int J Surg. 2021;95:106136.
Surgical site infections (SSI) are a common, yet largely preventable, complication of surgery which can result in increased length of stay and hospital readmission. In this review of 57 studies, the cumulative incidence of SSI was 11% in adult general surgical patients and was associated with increased length of stay (with variation by types of surgery).
Schnock KO, Biggs B, Fladger A, et al. J Patient Saf. 2021;17:e462-e468.
Hospitals have implemented radiofrequency identification (RFID) technology to improve patient safety. This systematic review of 5 studies suggests that use of RFID can lead to rapid, accurate detection of retained surgical instruments (RSIs) and reduced risk of counting errors.
Barbara L, Roberta DB, Vanda R, et al. J Patient Saf. 2022;18(2):e480-e488.
Patient safety indicators can help hospitals identify and prevent potential adverse events. Researchers in this study developed a conceptual framework for monitoring patient safety and a set of fifteen actionable patient safety indicators.
Abraham J, Pfeifer E, Doering M, et al. Anesth Analg. 2021;132:1563-1575.
Intraoperative handoffs between anesthesiologists are frequently necessary but are not without risk. This systematic review of 14 studies of intraoperative handoffs and handoff tools found that use of handoff tools has a positive impact on patient safety. Additional research is needed around design and implementation of tools, particularly the use of electronic health records to record handoffs.
Mcmullan RD, Urwin R, Gates PJ, et al. Int J Qual Health Care. 2021;33:mzab068.
Distractions in the operating room are common and can lead to errors. This systematic review including 27 studies found that distractions, interruptions, and disruptions in the operating room are associated with a range of negative outcomes. These include longer operative duration, impaired team performance, self-reported errors by colleagues, surgical errors, surgical site infections, and fewer patient safety checks.
Olivarius‐McAllister J, Pandit M, Sykes A, et al. Anaesthesia. 2021;76:1616-1624.
UK Regulators measure never events to assess hospital safety culture and dictate reimbursement. The authors suggest that regulators focus on reducing the national never event rate through shared learning and an integrated system-wide approach, rather than concentrating on underperforming, outlier hospitals where factors such as safety culture maybe contributing to increased rates of never events.
Fridrich A, Imhof A, Schwappach DLB. J Patient Saf. 2021;17:217-222.
Checklists are used across clinical areas. Following the publication of the World Health Organization’s (WHO) Surgical Safety Checklist in 2009, other organizations developed their own checklists or adapted the WHO Surgical Safety Checklist for local settings. The authors analyzed 24 checklists used in 18 Swiss hospitals, identified major differences between study checklists and reference checklists and provided recommendations for future research regarding the effectiveness of surgical safety checklists.
Gui JL, Nemergut EC, Forkin KT. J Clin Anesth. 2020;68:110110.
Distractions and interruptions are common in health care delivery. This literature review discusses the range of operating room distractions (from common events such as “small talk” to more intense distractions such as unavailable equipment) that can affect anesthesia practice, and their likely impact on patient safety.
Boet S, Djokhdem H, Leir SA, et al. Br J Anaesth. 2020;125:605-613.
Handoffs between providers can introduce patient safety risks. This systematic review explored the impacts of intraoperative anesthesia handovers (e.g., intraoperative relief, transferring care to an incoming provider) on patient safety outcomes. The researchers pooled four studies and found that an intraoperative anesthesia handover significantly increases the risk of an adverse event by 40%.
Merkow RP, Shan Y, Gupta AR, et al. Jt Comm J Qual Patient Saf. 2020;46:558-564.
Postoperative complications can increase costs due to additional healthcare utilization such as further testing, reoperation, or additional clinical services. This study used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to estimate 30-day costs resulting from postoperative complications. Prolonged ventilation, unplanned intubation, and renal failure were associated with the highest cost per event, whereas urinary tract infection, superficial surgical site infection, and venous thromboembolism were associated with the lowest cost per event.
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