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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 - 20 of 27 Results
Patient Safety Surveillance Unit. Department of Health, Perth: Western Australia.
This annual report shares the results of Western Australia's sentinel event reporting program. Medication errors were the highest recorded sentinel event in the latest period. The data is placed in the context of the overall data collected over the last 5 years of the program.
Siddiqui A, Ng E, Burrows C, et al. Cureus. 2019;11:e4376.
This randomized simulation study examined the use of checklists during simulated pediatric cardiac arrests in the surgical setting. Despite low uptake of the checklists, their availability during the simulations was associated with better performance. The authors recommend use of these checklists to enhance performance in rare critical situations.
Marshall SD, Chrimes N. Anaesthesia. 2019;74:280-284.
Medication errors in anesthesia practice can result in serious patient harm. This commentary examines factors that affect safety of medication delivery in the operating room. The authors provide recommendations to help individuals improve the reliability of their practice and describe human factors to consider to enhance safety.
Badgery-Parker T, Pearson S-A, Dunn S, et al. JAMA Intern Med. 2019;179:499-505.
Overuse of unnecessary tests and procedures contributes to patient harm. In this cohort study, researchers found that patients who developed a hospital-acquired condition after undergoing a procedure that most likely should not have been performed had longer lengths of stay than patients who did not develop a hospital-acquired condition.
Davis SS, Babidge WJ, McCulloch GAJ, et al. ANZ J Surg. 2019;89:764-768.
Clinical decision-making is a complex process affected by many factors and has important implications for patient outcomes. Using data from the Australian and New Zealand Audit of Surgical Mortality database over a 1-year period, researchers fully audited 3422 deaths and identified 226 cases involving a clinical decision-making incident (CDMI) thought to be concerning by reviewers. The most frequently noted incident was decision to operate, followed by diagnostic error and insufficient postoperative evaluation. The authors suggest that thorough discussion of complex cases in advance of surgery might mitigate CDMIs related to decisions to perform surgery and that retrospectively reviewing deaths for such CDMIs may supplement existing processes for reviewing and learning from surgical mortality. A WebM&M commentary discussed an incident involving a diagnostic error in which a patient was taken to the operating room for an unnecessary surgery.
Gillespie BM, Harbeck EL, Lavin J, et al. BMJ Open Qual. 2018;7:e000362.
Checklists like the Universal Protocol are a widely accepted strategy for reducing wrong site, wrong procedure, and wrong patient surgeries. The authors describe a campaign that improved checklist participation and completion in an academic hospital in Australia. A PSNet interview with Lucian Leape explored the challenges of achieving robust and universal use of checklists.
Ong APC, Devcich DA, Hannam J, et al. BMJ Qual Saf. 2016;25:971-976.
This hospital introduced large print, wall-mounted checklist posters in their operating rooms (ORs) and specifically assigned the leadership of each domain of the checklist to a different OR group (anesthesia, nursing, and surgery). These inexpensive changes led to improvements in team engagement and compliance with the surgical safety checklist process.
Merry A, Weller J, Mitchell SJ. J Cardiothorac Vasc Anesth. 2014;28:1341-51.
This review explores safety in cardiac surgery and suggests that the anesthesiologist in the surgical team is in the optimal position to maintain an overarching view of the care being provided to a patient, able to ensure that evidence-based practices are followed and appropriate care is delivered.
Collins SJ, Newhouse R, Porter J, et al. AORN J. 2014;100:65-79.e5.
Organizations including The Joint Commission, the World Health Organization, and the Centers for Medicare and Medicaid Services have focused on improving surgical safety. Using Reason's Swiss cheese model, this review analyzes the evidence for surgical checklist implementation to determine its usefulness in preventing wrong-site surgery and recommends tactics to address weaknesses.
Hannam JA, Glass L, Kwon J, et al. BMJ Qual Saf. 2013;22:940-7.
This observational study compared the implementation of the WHO Surgical Safety Checklist at a hospital in New Zealand with a neighboring hospital that had served as a pilot site for the study. They found that the pilot hospital adhered to the sign in, time out, and sign out procedures of the checklist more frequently than the hospital that adopted the checklist outside the context of a study. The non-pilot site did have engagement across more disciplines (anesthesia, surgery, nursing), compared with the nurse-only engagement at the pilot hospital. These findings shed light on the difficulty of implementing safety practices widely.
Watters DAK, Truskett PG. ANZ J Surg. 2013;83:434-437.
In the context of emergency surgery, this review summarizes error classification, error prevention strategies, and techniques for responding to adverse events.
Merry A, Webster CS, Hannam J, et al. BMJ. 2011;343:d5543.
Drug administration errors are a major safety concern in anesthesiology, as even routine cases can require administration of several high-risk medications. In this randomized controlled trial, a novel system for drug administration was evaluated in comparison with usual anesthesia practice. The new system was designed according to human factors engineering principles and included proven safety measures such as barcode medication administration. Although fewer overall errors occurred with the new system, the reduction in administration errors occurred only when barcoding was performed consistently and safety alerts were heeded. The anesthesia field has long been a leader in patient safety, and in fact, some of the earliest studies in the patient safety field evaluated the role of human factors in anesthesia medication administration errors.
Heard GC, Sanderson PM, Thomas RD. Anesthesia & Analgesia. 2011;114.
This survey found that anesthesiologists minimized the impact of attitudinal and emotional barriers on reporting unspecified adverse events, except for concerns about being blamed by colleagues. For specified events, the influence of perceived barriers was dependent on whether an error actually occurred.
World Health Organization.
This initiative provides a surgical safety checklist and related educational and training materials building on the Second Global Patient Safety Challenge vision to encourage international adoption of a core set of safety standards. Implementation of this World Health Organization’s checklist has resulted in dramatic reductions in surgical mortality and complications across diverse international hospitals. Surgical checklists have now become one of the clearest success stories in the patient safety movement, although some have described challenges to effective implementation. Dr. Atul Gawande discussed the history of checklists as a quality and safety tool in his book, The Checklist Manifesto: How to Get Things Right.