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Clinical Areas

Scroll down to search or browse using Clinical Area if you would like to explore PSNet by the healthcare profession, such as the nurse care or medical specialty, featured in the resources.

Latest by Clinical Areas

Agency for Healthcare Research and Quality Evidence-based Practice Center and the  Scientific Resource Center. April 29, 2024, 12:00-2:00 PM (eastern)

A commitment to evidence-based improvement is core to patient safety achievement. This webinar will highlight three reports from the Making Healthcare Safer IV series covering opioid stewardship... Read More

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Displaying 1 - 20 of 16119 Results
Post W, Thomas AD, Sutton KM. Birth. 2024;Epub Apr 2.
Structural racism and discrimination can impede safe maternal care. This qualitative study among Black women highlighted how their severe maternal morbidity (SMM) experiences relate to manifestations of racism through communication failures and stereotyping, differential treatment, and medical errors/near misses.
Brewer A, Hughes MC, Patel KN. J Patient Saf. 2024;20:198-201.
The Hospital-Acquired Condition (HAC) Reduction Program (HACRP) assesses penalties on hospitals with high rates of HAC. This study explores the impact of repeated HACRP penalties on hospital improvement and variation by hospital characteristics. When considering all hospitals, repeated HACRP penalties resulted in improved HAC scores. Hospitals with disproportionate shares of Medicare and Medicaid patients showed less improvement; the researchers note that the differential improvement may be due to resource limitations at hospitals serving vulnerable populations (i.e., Medicare and Medicaid patients).
Chen F, Wang L, Hong J, et al. J Am Med Inform Assoc. 2024;Epub Mar 23.
When biased data are used for research, the results may reflect the same biases if appropriate precautions are not taken. In this systematic review, researchers describe possible types of bias (e.g., implicit, selection) that can result from research with artificial intelligence (AI) using electronic health record (EHR) data. Along with recommendations to reduce introducing bias into the data model, the authors stress the importance of standardized reporting of model development and real-world testing.
Murphy DR, Kadiyala H, Wei L, et al. J Telemed Telecare. 2024;Epub Apr 1.
The expansion of telehealth has improved access to care, but concerns have been raised about potential for diagnostic errors. In this study, researchers used the Safer Dx Trigger tool framework to develop an electronic trigger to identify delayed diagnoses during primary care telehealth visits at a Veterans Health Affairs (VHA) facility. Applying the trigger tool to a random sample of 100 telehealth visits with a subsequent unplanned visit (emergency department, hospital or primary care) yielded a positive predictive value of 11%.
Sutherland AB, Phipps DL, Grant S, et al. Ergonomics. 2024;Epub Apr 1.
Medication errors are often the result of both individual failures and system flaws. This qualitative study found that medication safety practices in pediatric inpatient units are often hindered by issues in the physical environment (e.g., workspace layouts, interruptions) and by poorly integrated workflows.
Hults CM, Ding Y, Xie GG, et al. Cogn Res Princ Implic. 2024;9:18.
Inattentional blindness occurs when a person is focused so intently on one task that they miss other important information. This review identifies studies of inattentional blindness in healthcare, from radiology to surgery to nursing. The authors make recommendations on how to improve designing and reporting studies of inattentional blindness.

ISMP Medication Safety Alert! Acute care. April 4, 2024;29(7):1-4.

Safe medication therapy for transplant patients is complex and has the potential for serious harm when errors occur. This article reports on an analysis of 520 transplant medication-related errors to summarize the types of mistakes that occurred, and to provide suggestions for improvement that emphasize medication reconciliation, order set development, and clinical decision support use.
Sokol-Hessner L, Dechen T, Folcarelli P, et al. Jt Comm J Qual Patient Saf. 2024;Epub Mar 7.
Medical errors can cause physical, financial, or emotional harm to patients. This survey identified prolonged emotional impacts (greater than one year) among the majority of US adults who experienced a medical error. Survey respondents who were female or with a lower socioeconomic status were more likely to report prolonged emotional impacts; organizational factors such as lack of organizational disclosure guidelines and no patient or family reporting process also increased risk of prolonged emotional impacts.
Camacho EM, Gavan S, Keers RN, et al. BMJ Qual Saf. 2024;Epub Mar 26.
Transitions of care introduce risk of medication errors, even with interoperable electronic medication systems; systems that do not communicate with each other introduce even more risk. This study estimates the prevalence and burden of medication errors at transitions of care (hospital admission, hospital discharge, transfers between hospitals, and transfers within hospitals) when electronic medication records are not interoperable. Implementing interoperable prescribing systems could significantly reduce the number of errors and prevent medication error-related patient deaths.

Agency for Healthcare Research and Quality Evidence-based Practice Center and the  Scientific Resource Center. April 29, 2024, 12:00-2:00 PM (eastern)

A commitment to evidence-based improvement is core to patient safety achievement. This webinar will highlight three reports from the Making Healthcare Safer IV series covering opioid stewardship, rapid response systems, and the involvement of family caregivers as participants in structured communication during care transitions.
Strandås M, Vizcaya-Moreno M, Ingstad K, et al. J Multidiscip Healthc. 2024;17:1385-1400.
Paramedics often provide critical medical care during complex, high-stress scenarios. This systematic review of 16 studies found that paramedics encounter a myriad of challenges in maintaining safe patient care (e.g., uncertainties about role expectations, insufficient resources). Studies highlighted the effectiveness of interventions to increase technical and non-technical skills and improve communication and collaboration to promote patient safety.
Crowe L, Riley CM. Curr Opin Cardiol. 2024;Epub Mar 21.
Unprofessional behavior negatively impacts the work environment, team functioning, and patient safety. Women, minoritized, and junior staff are more likely to be the targets of unprofessional behavior and are less likely to report it due to fear of retaliation or thinking nothing will be done to curb the perpetrator's behavior. Clear and consistent organizational commitment to address unprofessional behavior can mediate many of the negative patient safety impacts.

Manchester, UK: Parliamentary and Health Service Ombudsman; March 2024.

The provision of safe mental health care is receiving increased attention as an area of concern. This report examined six incidents of poor discharge care for patients with mental health conditions. The authors highlight system issues exacerbating the failures discussed and provide recommendations for improvement.
Cabral S, Restrepo D, Kanjee Z, et al. JAMA Intern Med. 2024;Epub Apr 1.
Research into how large language models (LLM) such as ChatGPT can be used in healthcare is growing rapidly. This study compared ChatGPT and physicians' clinical reasoning in a simulated case study. Using the validated Revised-IDEA (R-IDEA) framework, the LLM performed better than physicians did in processing medical data and clinical reasoning; there were no differences observed using other frameworks.

Dorset, UK: Health Services Safety Investigations Body; April 2024.

Retained surgical items are never events that continue to occur despite efforts to reduce their occurrence. This report examines reasons for 31 incidents of retained surgical swabs reported in the United Kingdom’s National Health Service (NHS). Recommendations from the analysis focus on organizational work to limit the opportunities for swab retention that target system improvement rather those that lower impact changes directed toward staff behavior and training.
WebM&M Case April 10, 2024

An 82-year-old woman presented to the emergency department for evaluation of “altered mental status” after falling down 5 step-stairs at home. She had a Glasgow Coma Score of 11 (indicating decreased alertness) on arrival. Computed tomography (CT) of the head revealed a right thalamic hemorrhage. She was admitted to the Vascular Neurology service. Overnight, the patient developed atrial fibrillation with rapid ventricular rate (RVR), which required medications for rate control.

Patient Safety Innovation April 10, 2024

North American Partners in Anesthesia (NAPA) is a nationwide anesthesia practice with more than 450 facilities in 21 states. NAPA employs anesthesiologists, certified registered nurse anesthetists, and certified anesthesiologist assistants.

WebM&M Case April 10, 2024

A 61-year-old patient presented to the emergency department (ED) complaining of weakness with findings of shuffling gait, slurred speech, delayed response to questions, and inability to concentrate or make eye contact. A stroke alert was activated and a neurosurgeon evaluated the patient via teleconsult. There was no intracranial hemorrhage identified on non-contrast computed tomography (CT) of the head and the neurosurgeon recommended administering Tenecteplase (TNK).

Li L, Baker J, Quirk R, et al. Drug Saf. 2024;Epub Mar 13.
Drug-drug interactions (DDI) can be harmful. This study examined frequency of potential DDI (pDDI) and clinically relevant DDI (cDDI) in three hospitals both before and after implementation of an electronic medication management (EMM) system, without accompanying decision support alerts. The frequency of pDDI and cDDI orders did not differ between timeframes, although the likelihood of both drugs being co-administered was lower post-EMM implementation. Only one-quarter of pDDI were clinically relevant, and actual harm was less than 1% in both timeframes and was primary mild. Given the low prevalence of actual harm and the decreased likelihood of co-administration of drugs even without alerts, caution should be used when implementing DDI alerts so as not to introduce alert fatigue.