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

Diagnostic Safety Toolkit.

Washington DC: Association of American Medical Colleges; 2022.

Effective communication is critical as patients shift from one level of care to another as their diagnosis evolves. This toolkit is designed to help academic medical centers initiate conversations to improve diagnostic... Read More

People’s Experiences of Diagnosis.

London, England: National Voices; 2024.

To forgive, divine.

Johnson V. N Engl J Med. 2024;391:6-7.

Frequency and preventability of adverse drug events in the outpatient setting.

Wasserman RL, Edrees HH, Amato MG, et al. BMJ Qual Saf. 2024;Epub Jul 9.

Adverse drug events (ADEs) remain a persistent patient safety challenge. This retrospective analysis of 3,323 patients treated in outpatient settings in 2018 found that 5%... Read More

All Clinical Areas (16198)

Displaying 1 - 20 of 16340 Results

Study

Long-term care healthcare-associated infections in 2023: an analysis of 23,970 reports.

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Kepner S, Bennett A, Jones RM. Patient Safety. 2024;6.

Preventing healthcare-associated infections continue to be a challenge in long-term care settings. Based on reports submitted by long-term care facilities to the Pennsylvania Patient Safety Reporting System (PA-PSRS), infection rates increased for skin and soft tissue, urinary tract, and respiratory tract infections. This continues the trend seen in the 2022 report.

Study

A human right-based approach to dealing with adverse events in residential care facilities.

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McGrane N, Behan L, Keyes LM. Health Hum Rights. 2024;26:115-128.

Many regulatory authorities require notification of adverse events involving vulnerable individuals, such as those in care facilities. In this study, almost 200 statutory notifications from residential care facilities (RCF; e.g., nursing homes, assisted living) were analyzed to ensure residents' human rights (fairness, respect, equality, dignity, and autonomy) were upheld during adverse events. In the majority of adverse events and their management, residents' human rights were upheld.

Study

Partnership as a pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning Lab.

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Sloane J, Singh H, Upadhyay DK, et al. Jt Comm J Qual Patient Saf. 2024;Epub May 31.

Improving the diagnostic process requires multipronged and multidisciplinary approaches to achieve lasting improvements. This qualitative study involving 25 individuals associated with the Safer Dx Learning Lab identified several program successes, such as improved reporting workflow and safety culture fostering psychological safety. Participants also highlighted lessons learned, including leadership buy-in and the need for protected time for clinicians to participate in case review and continuous learning.

Study

Living with the aftermath: the second victim experience among certified registered nurse anesthetists.

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Kruse JA, Podojil-Kostecki P, Smith B. AANA J. 2024;92:173-180.

Many healthcare staff who are involved in an adverse event may experience negative physical and psychological aftereffects. This study of certified registered nurse anesthetists (CRNA) in Michigan found 20% of respondents experienced psychological distress and 16% experienced physical distress. Peer support was the most important type of support following an event. Institutional support was inadequate.

Study

A clinical pharmacist-led transitions of care program for veterans with two planned care transitions (hospital to skilled care and skilled care to home) amid the COVID-19 pandemic.

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Scannell GA, Bevan DJ, Cowan A, et al. J Am Med Dir Assoc. 2024;25:105006.

Transitions of care between health care settings and home can introduce opportunities for adverse events, particularly among vulnerable patients. This article describes the pilot implementation of the Geriatric High-Risk Evaluation and Liaison Program – Transitional Care (GHELP-TC) which aims to improve care transitions between acute care to skilled nursing and skilled nursing to home for older veterans. This pilot evaluation identified 79 medication errors and 80 appointment errors among 90 enrolled veterans. A planned expanded implementation will include registered nurses (RNs) to improve communication and accountability.

Study

How can interventions more directly address drivers of unprofessional behaviour between healthcare staff?

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Aunger JA, Abrams R, Mannion R, et al. BMJ Open Qual. 2024;13:e002830.

Disruptive and unprofessional behavior jeopardizes patient safety and the overall quality of care. This paper underlines the importance of mapping the individual drivers of unprofessional behavior to strategies that address them. The authors’ program theory (PT) maps drivers and strategies to serve as a basis for developing evidence-based interventions to reduce unprofessional behavior.

Book/Report

People’s Experiences of Diagnosis.

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London, England: National Voices; 2024.

The discussion of diagnostic safety has expanded to include an effort to realize excellence. This report explores the diagnostic process in the United Kingdom to reveal contributing factors to inequalities, biases, and delays that result in misdiagnosis and limited care. The authors highlight successes that support patient-centered care, including multidisciplinary teams, improved communication, and access to specialists.

Study

Seeking systems-based facilitators of safety and healthcare resilience: a thematic review of incident reports.

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Leon C, Hogan H, Jani YH. Int J Qual Health Care. 2024;36:mzae057.

Incident reports provide valuable learning opportunities at individual, team, and organizational levels. This study used incident reports involving anticoagulant medication errors to demonstrate the effectiveness of Systems Engineering Initiative for Patient Safety (SEIPS) and healthcare resilience as an alternative investigative approach. Report descriptions included all the SEIPS components and resilience capacities (e.g., preparedness, adaptation), indicating this method can be used to complement traditional investigative methods.

Study

Frequency and preventability of adverse drug events in the outpatient setting.

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Wasserman RL, Edrees HH, Amato MG, et al. BMJ Qual Saf. 2024;Epub Jul 9.

Adverse drug events (ADEs) remain a persistent patient safety challenge. This retrospective analysis of 3,323 patients treated in outpatient settings in 2018 found that 5% experienced an ADE. Most ADEs involved cardiovascular, central nervous system, or anti-infective medications. The researchers concluded that 22% of these ADEs were likely preventable through strategies such as improved education, training, communication, and monitoring or the use of clinical decision support tools or alerts.

Study

A multifaceted risk management program to improve the reporting rate of patient safety incidents in primary care: a cluster-randomised controlled trial.

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Chanelière M, Buchet-Poyau K, Keriel-Gascou M, et al. BMC Prim Care. 2024;25:244.

Voluntary incident reporting remains low despite its demonstrated importance in improving patient safety. This randomized controlled trial tested the impact of a multidisciplinary effort to increase event reporting in primary care settings. The intervention included e-learning training modules, identification of a risk management advisor, and multidisciplinary meetings focused on patient safety incidents at each facility. Only 7 of the 17 facilities fully implemented the program, and there were no improvements in reporting rates in intervention or control facilities.

Commentary

Patient falls in the operating room: why is this still a problem in 2024?

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Pellegrino A, Brook K. J Patient Saf. 2024;Epub Jun 28.

Patient falls are a never event; every fall should be reported and thoroughly investigated. This commentary describes the challenges of using national falls databases to learn from falls occurring in the periprocedural environment. The authors recommend a national database specific to periprocedural falls and offer suggestions on prevention of falls in and around the operating room.

Study

Clinical decision support as a prevention tool for medication errors in the operating room: a retrospective cross-sectional study.

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Amici LD, van Pelt M, Mylott L, et al. Anesth Analg. 2024;Epub Jun 13.

Computerized clinical decision support (CDS) helps prevent medication errors throughout the medication process. This study evaluated self-reported medication errors in the operating room to establish if CDS could have prevented them. Eighty medication errors were reported with 95% determined to be potentially preventable with CDS. All wrong medication, wrong dose, and documentation errors were rated as potentially preventable.

Commentary

To forgive, divine.

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Johnson V. N Engl J Med. 2024;391:6-7.

Resident physicians are vulnerable to psychological harm when they have made a mistake. This commentary shares one resident’s experiences with error. The author discusses the importance of finding support and sharing experiences with colleagues who have been challenged by errors and managing their impact to assist in the return of their confidence to practice.

United States Meeting/Conference

National Action Alliance to Advance Patient and Workforce Safety Webinar Series.

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US Department of Health and Human Services. 2023-2024.

Work toward zero harm in health care is gaining national attention in the United States. These webinars align with efforts by the National Action Alliance to Advance Patient and Workforce Safety. There have been nine videos in this series of offerings from the Alliance supporting its work to improve safety. Two upcoming sessions reviewing safety competencies and diagnostic safety research are open for registration.

Study

Machine learning evaluation of inequities and disparities associated with nurse sensitive indicator safety events.

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Georgantes ER, Gunturkun F, McGreevy TJ, et al. J Nurs Scholarsh. 2024;Epub May 21.

Nurse sensitive indicators (NSI) can help organizations identify areas for improvement. Rates of three nurse sensitive indicators - falls, healthcare associated pressure injuries, and healthcare associated infections - in one hospital were analyzed to identify if disparities exist and to create a model for identifying patients at risk. Patients with at least one NSI were more likely to have been admitted emergently, admitted to the ICU, and have longer ICU and hospital stays than patients with no NSI. Race/ethnicity was not associated with the risk of experiencing an NSI.

United States Meeting/Conference

Human Factors Workshop: A Systems Approach to Patient Safety.

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Medstar Health. MedStar Health Central Office, Columbia, MD, September 12-13, 2024.

Human factors strategies are a core approach to mitigating the impact of human error in medicine. This workshop will provide a safety science context to the application of human factors engineering to health care. The complementary approaches will be infused with discussions on event review and proactive safety improvement efforts.

Grant Announcement

Examining the Impact of Artificial Intelligence (AI) on Healthcare Safety (R18).

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Rockville, MD: Agency for Research and Quality; July 15, 2024. PA-24-261.

Health systems are increasingly developing, testing, and deploying artificial intelligence (AI) to support patient care. This funding opportunity focuses on assessing the impact, both positive and negative, of actual AI deployments in healthcare delivery systems and how that impact can be affected by implementation and use strategies.

Multi-use Website

TeamSTEPPS for Diagnosis Improvement.

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Rockville, MD: Agency for Healthcare Research and Quality; March 2022.

The recognition of diagnosis as a team activity is energizing new diagnostic process initiatives. Building on the established TeamSTEPPS® principles, this new TeamSTEPPS course includes seven training modules, team and knowledge assessment tools, and implementation guidance to develop or enhance communication across the care team to improve the accuracy and timeliness of diagnosis. Training opportunities in the summer of 2024 are now available for registration.

Multi-use Website

MR Safety Week.

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International Society for Magnetic Resonance in Medicine.

MRI Safety Week is held annually in July. This observance supports the sharing of information and resources to support magnetic resonance imaging safety.

Review

Systematic review of types of safety incidents and the processes and systems used for safety incident reporting in care homes.

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Scott J, Sykes K, Waring J, et al. J Adv Nurs. 2024;Epub Jun 19.

Incident reporting systems are commonly used to detect threats to patient safety. This systematic review of 106 studies examined the characteristics of incident reporting processes in residential care facilities and nursing homes in high-income countries. The authors summarize how incidents are detected; common contributing, mitigating, and ameliorating factors; as well as actions and interventions to reduce the risk of patient safety incidents.

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