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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 - 14 of 14 Results
St Paul, MN: Minnesota Department of Health.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.
Anderson JE, Watt AJ. Int J Qual Health Care. 2020;32:196-203.
Using a Safety-II framework, the authors used a mixed-methods approach to retrospectively analyze root cause analysis (RCA) reports of ‘never events’ occurring in the United Kingdom to characterize proposed actions, insights and recommendations to prevent future events. The analysis found that proposed actions were generally of low-to-moderate effectiveness, and that despite identifying systems challenges and weaknesses, many reports did not include proposed actions to mitigate or remove risks. The authors conclude that applying concepts from resilient healthcare can identify vulnerabilities and opportunities for strengthening the RCA system and improving the quality of RCA reports.
Patient Safety Primer September 7, 2019
The list of never events has expanded over time to include adverse events that are unambiguous, serious, and usually preventable. While most are rare, when never events occur, they are devastating to patients and indicate serious underlying organizational safety problems.
Shah RK, Boss EF, Brereton J, et al. Otolaryngol Head Neck Surg. 2014;150:779-784.
This survey of otolaryngologists found very little overall progress in self-reported patient safety errors compared with a similar survey in 2004. For instance, wrong-site surgeries continue to occur despite garnering major attention over the past decade and being classified as a never event.
Joint Commission.
The Joint Commission has traditionally focused on accreditation of health care organizations and, through its Joint Commission Resources arm, on quality improvement (QI) in areas related to its accreditation functions. In the first major initiative under the leadership of new president Dr. Mark Chassin, The Joint Commission launched this Center, which will focus on applying rigorous QI methods to improve safety in a number of challenging areas (the first three are hand hygiene, handoff communication, and preventing wrong site surgery) and disseminating the lessons from these efforts. This video set provides information about the Center and its goals.
Herper M; Lindner M.
This article discusses common medical complications and care failures, and provides an annotated picture gallery of several hospital complications and how they can be prevented.

Blum A. Bloomberg. August 14, 2006.

This article discusses how hospital design, including standardized operating rooms, better ventilation systems, and green design can improve patient safety and decrease costs.