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psnet.ahrq.gov/issue/addressing-bias-acute-postoperative-pain-management
September 23, 2020 - Review
Addressing bias in acute postoperative pain management.
Citation Text:
Harbell MW, Maloney J, Anderson MA, et al. Addressing bias in acute postoperative pain management. Curr Pain Headache Rep. 2023;27(9):407-415. doi:10.1007/s11916-023-01135-0.
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psnet.ahrq.gov/issue/patient-safety-advisory-fentanyl-counterfeit-prescription-medications-contain-fentanyl-and
September 18, 2024 - Organizational Policy/Guidelines
Patient Safety Advisory: fentanyl counterfeit prescription medications that contain fentanyl and patient safety.
Citation Text:
Jewell ML, Jewell HL, Singer R, et al. Patient Safety Advisory: fentanyl counterfeit prescription medications that contain fent…
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psnet.ahrq.gov/issue/unintended-transplantation-three-organs-hiv-positive-donor-report-analysis-adverse-event
January 24, 2018 - Commentary
Unintended transplantation of three organs from an HIV-positive donor: report of the analysis of an adverse event in a regional health care service in Italy.
Citation Text:
Bellandi T, Albolino S, Tartaglia R, et al. Unintended transplantation of three organs from an HIV-posi…
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psnet.ahrq.gov/issue/society-maternal-fetal-medicine-special-statement-surgical-safety-checklists-cesarean
May 18, 2022 - Organizational Policy/Guidelines
Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery.
Citation Text:
Combs CA, Einerson BD, Toner LE. Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean deliver…
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psnet.ahrq.gov/issue/evolution-anesthesia-patient-safety-movement-america-lessons-learned-and-considerations
September 14, 2022 - Commentary
The evolution of the Anesthesia Patient Safety Movement in America: lessons learned and considerations to promote further improvement in patient safety.
Citation Text:
Warner MA, Warner ME. The evolution of the Anesthesia Patient Safety Movement in America: lessons learned and…
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psnet.ahrq.gov/issue/standardization-and-visualization-surgical-time-out
November 06, 2024 - Study
Standardization and visualization of the surgical time-out.
Citation Text:
Levy BE, Wilt WS, Lantz S, et al. Standardization and visualization of the surgical time-out. J Patient Saf. 2023;19(7):453-459. doi:10.1097/pts.0000000000001156.
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psnet.ahrq.gov/issue/association-between-paediatric-intraoperative-anaesthesia-handover-and-adverse-postoperative
July 21, 2021 - Study
Association between paediatric intraoperative anaesthesia handover and adverse postoperative outcomes.
Citation Text:
Kannampallil TG, Lew D, Pfeifer EE, et al. Association between paediatric intraoperative anaesthesia handover and adverse postoperative outcomes. BMJ Qual Saf. 2021…
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psnet.ahrq.gov/issue/human-factors-analysis-technical-and-team-skills-among-surgical-trainees-during-procedural
March 03, 2011 - Study
A human factors analysis of technical and team skills among surgical trainees during procedural simulations in a simulated operating theatre.
Citation Text:
Moorthy K, Munz Y, Adams S, et al. A human factors analysis of technical and team skills among surgical trainees during pro…
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psnet.ahrq.gov/issue/understanding-complaints-made-about-surgical-departments-uk-district-general-hospital
September 23, 2020 - Study
Understanding complaints made about surgical departments in a UK district general hospital.
Citation Text:
Claydon O, Keeler B, Khanna A. Understanding complaints made about surgical departments in a UK district general hospital. Int J Qual Health Care. 2021;33(3). doi:10.1093/intq…
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psnet.ahrq.gov/issue/engaging-patient-and-family-surgical-safety-process-utilizing-safestart
October 19, 2022 - Study
Engaging the patient and family in the surgical safety process utilizing SafeStart.
Citation Text:
Elger BM, Esparaz JR, Nierstedt RT, et al. Engaging the patient and family in the surgical safety process utilizing. J Pediatr Surg. 2020;55(4). doi:10.1016/j.jpedsurg.2019.06.012.
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psnet.ahrq.gov/issue/explainable-artificial-intelligence-safe-intraoperative-decision-support
October 13, 2015 - Commentary
Explainable artificial intelligence for safe intraoperative decision support.
Citation Text:
Gordon L, Grantcharov T, Rudzicz F. Explainable Artificial Intelligence for Safe Intraoperative Decision Support. JAMA Surg. 2019. doi:10.1001/jamasurg.2019.2821.
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psnet.ahrq.gov/web-mm/wrong-side-bedside-paravertebral-block-preventing-preventable
August 10, 2019 - Wrong-side Bedside Paravertebral Block: Preventing the Preventable
Citation Text:
Barrington MJ, Uda Y. Wrong-side Bedside Paravertebral Block: Preventing the Preventable. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017.
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psnet.ahrq.gov/node/49725/psn-pdf
January 01, 2015 - Haste Makes Care Unsafe
January 1, 2015
Eichhorn JH. Haste Makes Care Unsafe. PSNet [internet]. 2015.
https://psnet.ahrq.gov/web-mm/haste-makes-care-unsafe
The Case
An 80-year-old man with a history of coronary artery disease and atrial fibrillation underwent a combined
elective coronary artery bypass graft (CABG…
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psnet.ahrq.gov/periodic-issue/periodic-issue-473
March 25, 2025 - March 5, 2025 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly
Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient
safety literature, news, conferences, reports, …
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psnet.ahrq.gov/web-mm/navigating-chaos-fatal-iatrogenic-liver-injury-patient-admitted-leg-fractures
November 27, 2019 - Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures
Citation Text:
Loseth C. Navigating Chaos: Fatal Iatrogenic Liver Injury in a Patient Admitted for Leg Fractures. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and …
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psnet.ahrq.gov/node/44575/psn-pdf
January 22, 2016 - A narrative review of high-quality literature on the effects
of resident duty hours reforms.
January 22, 2016
Lin H, Lin E, Auditore S, et al. A Narrative Review of High-Quality Literature on the Effects of Resident Duty
Hours Reforms. Acad Med. 2016;91(1):140-50. doi:10.1097/ACM.0000000000000937.
https://psnet.ah…
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psnet.ahrq.gov/node/838251/psn-pdf
October 05, 2022 - Serious hazards of transfusion: evaluating the dangers of
a wrong patient autologous salvaged blood in cardiac
surgery.
October 5, 2022
Uramatsu M, Maeda H, Mishima S, et al. Serious hazards of transfusion: evaluating the dangers of a wrong
patient autologous salvaged blood in cardiac surgery. J Cardiothorac Surg.…
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psnet.ahrq.gov/node/41319/psn-pdf
May 17, 2012 - Nature and timing of incidents intercepted by the
SURPASS checklist in surgical patients.
May 17, 2012
de Vries EN, Prins HA, Bennink C, et al. Nature and timing of incidents intercepted by the SURPASS
checklist in surgical patients. BMJ Qual Saf. 2012;21(6):503-8. doi:10.1136/bmjqs-2011-000347.
https://psnet.ahrq…
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psnet.ahrq.gov/node/47000/psn-pdf
May 09, 2018 - 'Broken hospital windows': debating the theory of
spreading disorder and its application to healthcare
organizations.
May 9, 2018
Churruca K, Ellis LA, Braithwaite J. 'Broken hospital windows': debating the theory of spreading disorder
and its application to healthcare organizations. BMC Health Serv Res. 2018;18(1…
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psnet.ahrq.gov/node/43349/psn-pdf
July 16, 2014 - Multifaceted interventions improve adherence to the
surgical checklist.
July 16, 2014
Putnam LR, Levy SM, Sajid M, et al. Multifaceted interventions improve adherence to the surgical checklist.
Surgery. 2014;156(2):336-344. doi:10.1016/j.surg.2014.03.032.
https://psnet.ahrq.gov/issue/multifaceted-interventions-imp…