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.
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.
Poor communication regarding medical errors can contribute to patient and family frustration and fear. Reporting on a case involving disclosure of a wrong-site surgery, this news article describes a resolution program to help patients cope after a preventable error. The program includes apology, disclosure, and explanation of what occurred as well as financial compensation.
Clarke JR. PA-PSRS Patient Saf Advis. 2015;12:19-27.
Wrong-site surgeries are considered never events by the National Quality Forum and sentinel events by The Joint Commission. Drawing from data submitted to the Pennsylvania Patient Safety Authority, this article analyzes 83 wrong-site extremity procedures in orthopedic surgery reported over 9 years and recommends site marking and time outs as strategies to prevent these incidents.
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.
Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1
In the context of system failures that contributed to the death of a patient, this newspaper article describes how never events are rarely publicized, even though hospital inspection reports are public records.
National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194.
This report resulted from a consensus program involving 28 national organizations that sought to outline goals for improving the US health care system and share examples of such efforts in patient safety and other identified areas.
Waterman AD, Gallagher TH, Garbutt J, et al. J Gen Intern Med. 2006;21:367-70.
This AHRQ–funded study used more than 2000 telephone interviews with recently discharged patients to demonstrate that patients who are most comfortable with error prevention were more likely to take specific action compared to those who are less comfortable. The authors report that although the majority of patients expressed comfort in asking questions about medications and general medical questions, far fewer actively engaged in marking their incision site or asking about handwashing. A past study discussed how to improve patients' perceptions of safety in hospitals, including educational interventions that might empower patients to take greater preventive action, as outlined in this study.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.