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.
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.
Algie CM, Mahar RK, Wasiak J, et al. Cochrane Database Syst Rev. 2015;3):CD009404.
Wrong-site surgery is considered a never event, and therefore hospitals have been required to implement protocols to prevent these errors. This systematic review did not identify any high-quality studies of successful methods to prevent wrong-site, wrong-patient, or wrong-procedure errors.
Department of Health of Western Australia, Patient Safety Directorate. Perth: Department of Health WA; 2011.
This report shares the 2010-2011 results of Western Australia's sentinel event reporting program. Patient suicide is the highest recorded sentinel event. The data is placed in the context of the overall data collected since the program's launch in 2003.
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