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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 - 3 of 3 Results
Uramatsu M, Maeda H, Mishima S, et al. J Cardiothorac Surg. 2022;17:182.
Wrong-patient transfusion errors can lead to serious patient harm. This case report describes a blood transfusion error and summarizes the systems issues that emerged during the root case analysis, as well as the corrective steps implemented by the hospital to prevent future transfusion errors. A previous Spotlight Case featured a near-miss transfusion error and strategies for ensuring safe transfusion practices.
Rice-Townsend S, Hall M, Jenkins KJ, et al. J Pediatr Surg. 2010;45:1126-36.
This study sought to characterize the incidence and types of adverse events in pediatric surgery patients, using measures (the National Surgical Quality Improvement Program and the AHRQ Patient Safety Indicators) originally developed for identifying adverse events in adults. The authors argue that applying adult measures to a pediatric population overestimates the incidence of adverse events.