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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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Curated Libraries
September 13, 2021
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization,teamwork, unit-based safety initiatives, and...
Berman L, Rialon KL, Mueller CM, et al. J Pediatr Surg. 2021;56:833-838.
Clinicians who are involved in an adverse even often experience emotional and psychological distress afterwards. A survey found that 80% of responding pediatric surgeons had personally experienced a medical error resulting in significant patient harm or death. Only one-quarter of those respondents were satisfied with the institutional support they received afterwards. Respondents cited numerous barriers (lack of trust, blame, shame) to receiving support.    
Buhlmann M, Ewens B, Rashidi A. J Clin Nurs. 2020;30:1195-1205.
Adverse events can have significant impacts on the providers involved. This systematic review explored the experiences of critical incidents on nurses and midwives and their perceived support from the healthcare system. The article discusses the emotional, physical, and professional impacts; perceptions of personal, peer and workplace support; and how nurses and midwives move forward and cope with the impact of critical incidents.  
Potential deterioration of an aging surgeon's technical abilities is an emerging patient safety concern. This magazine article discusses how implementing policies and activities to assess the ability of surgeons to practice safely after a certain age can prevent risks.
WebM&M Case June 1, 2019
During surgery for a forearm fracture, a woman experienced a drop in heart rate to below 50 beats per minute. As the consultant anesthesiologist had stepped out to care for another patient, the resident asked the technician to draw up atropine for the patient. When the technician returned with an unlabeled syringe without the medication vial, the resident was reluctant to administer the medication, but did so without a double check after the technician insisted it was atropine. Over the next few minutes, the patient's blood pressure spiked to 250/135 mm Hg.
Nguyen S, Corrington A, Hebl MR, et al. JAMA Surg. 2019;154:555-557.
Prior research has shown that certain surgeon behaviors are associated with an increased risk of malpractice claims, but less is known about how certain patient factors such as sleep may impact patients' desire to pursue litigation and seek financial compensation. In this study, researchers randomized healthy adults to normal sleep and sleep-restriction. After 4 nights, participants read and rated eight medical error vignettes. Sleep restriction was associated with increased desire to punish the surgeons and provide greater financial compensation to the patients described in the vignettes.
BMJ. 2018;363:k3033.
Patients who experience care complications are vulnerable to psychological consequences that can affect their relationship with their clinical teams. This commentary relates insights from a patient who experienced complications resulting from care, the negative impact on her relationship with her surgeon, and how she felt when her surgeon expressed empathy. The author offers recommendations for clinicians to demonstrate their concern and improve practice when problems occur.
Beil L. ProPublica. October 2, 2018.
This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted in patient harm. A past PSNet perspective explored the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
Abd Elwahab S, Doherty E. The Surgeon. 2014;12.
Medical errors affect not only the patients and families involved, but the clinicians and organization as well. This commentary focuses on physicians as second victims and how mistakes influence their emotional health, stress levels, and work performance.
WebM&M Case May 1, 2004
Owing to privacy concerns, a nurse draws the drapes on a 3-year-old child in recovery following surgery, and unfortunately does not realize the child is in distress until loud inspiratory stridor is heard.
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.