Clinical Areas

Browse using Clinical Area if you would like to explore PSNet by the healthcare profession, such as the nursing or medical specialty, featured in the resources.

Latest by Clinical Areas

WebAIRS Anesthesia Incident Reporting System.

Australian and New Zealand Tripartite Anaesthetic Data Committee.

Reporting errors in anesthesiology practice can motivate and inform safety improvement work. This website serves as a secure mechanism for submitting incident reports to a centralized... Read More

NPSD Data Spotlight: Patterns of Fall Interventions.

Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-0055.

Intravenous (IV) push medications – bridging the gap between education and clinical practice.

ISMP Medication Safety Alert! Acute Care. November 2, 2023;28(22):1-4.

Intravenous (IV) push medication administration is a primary therapeutic approach where process gaps can result in harm. This article examines existent... Read More

Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.

Maternal health care is rapidly emerging as a high-risk service that is vulnerable to communication, equity, and diagnostic challenges. This report examines... Read More

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Displaying 1 - 20 of 15742 Results

Creating Workforce Joy and Wellbeing.

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Institute for Healthcare Improvement. March 6 - May 20, 2024.

Burnout among health care workers negatively affects system improvement. This webinar series will highlight strategies to establish a healthy work environment that strengthens teamwork, staff engagement, and resilience. Instructors include Dr. Donald Berwick and Derek Feeley.

State of Care.

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Newcastle Upon Tyne, UK: Care Quality Commission; October 2023.

This website provides access to an annual report that summarizes National Health Service hospital and social care performance across a range of care quality metrics at both the trust and service level. The 2022-2023 report found substantial weaknesses in specialty areas such as emergency and maternal care and recognized workforce wellbeing issues that impact access and quality.

Informatics tools in deprescribing and medication optimization in older adults: development and dissemination of VIONE methodology in a high reliability organization.

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Winter SG, Sedgwick C, Wallace-Lacey A, et al. Clin Ther. 2023;45:928-934.

The VIONE (Vital, Important, Optional, Not indicated, and Every medication has an indication) tool is used to reduce polypharmacy and potentially inappropriate prescribing. This article provides an overview of VIONE implementation and dashboards used to track VIONE implementation and its impact on prescribing across over 130 Veterans Health Administration medical centers. Since implementation in 2016, VIONE has led to the discontinuation of over 1.6 million medication orders by more than 15,000 providers.

Artificial intelligence-supported screen reading versus standard double reading in the Mammography Screening with Artificial Intelligence trial (MASAI): a clinical safety analysis of a randomised, controlled, non-inferiority, single-blinded, screening accuracy study.

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Lång K, Josefsson V, Larsson A-M, et al. Lancet Oncol. 2023;24:936-944.

Retrospective studies have shown artificial intelligence (AI) to be at least as accurate as radiologists in detecting breast cancer in screening mammograms. This prospective randomized trial similarly demonstrated that AI readings were as accurate as double readings by radiologists, but with a significantly reduced workload.

Using stakeholder intervention refinement teams to develop approaches for real-time integration of patient-reported safety information during older adults’ hospital-to-home-health care transitions.

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Arbaje AI, Greyson S, Keita Fakeye M, et al. J Patient Saf Risk Manag. 2023;28:201-207.

Older adult patients and family caregivers face numerous safety challenges when transitioning from the hospital to skilled home health (HH). This article describes how older adults and their family caregivers, HH frontline providers, HH leadership, and HH hospital-based transition coordinators, were engaged to identify best practices to implement the Hospital-to-Home Health Transition Quality (H3TQ) Index. This participatory co-design process identified ways patients, caregivers, and staff differ in how and when to administer the H3TQ Index, confirming the importance of engaging a wide range of stakeholders in design processes.

NPSD Data Spotlight: Patterns of Fall Interventions.

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Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-0055.

Falls are a frequently reported sentinel event. This Data Spotlight from AHRQ’s Network of Patient Safety Databases (NPSD) highlights the most common interventions in place among patients who experienced a fall such as nonslip wear, bed height and visible risk identification. Data for the analysis includes reports on patient safety concerns submitted from 2009 through 2021.

Intravenous (IV) push medications – bridging the gap between education and clinical practice.

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ISMP Medication Safety Alert! Acute Care. November 2, 2023;28(22):1-4.

Intravenous (IV) push medication administration is a primary therapeutic approach where process gaps can result in harm. This article examines existent presence of recognized safe practice education in close to 200 surveyed nursing programs to assess the teaching of standardized practice behaviors at the student level and recommend strategies to embed IV safety into instruction efforts.

Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.

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National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.

Maternal health care is rapidly emerging as a high-risk service that is vulnerable to communication, equity, and diagnostic challenges. This report examines the role of disparities in care across the maternal care continuum and strategies to drive diagnostic improvement such as care bundles, midwives, and health information technology. This publication is from a series of programs and resultant publications on improving diagnostic excellence.

Medication Safety for Look-alike, Sound-alike Medicines.

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Galappatthy P, Mair A, Dhingra-Kumar N et al. Geneva, Switzerland: World Health Organization; 2023. ISBN 9789240058897.

Look-alike, sound-alike (LASA) medicines are known contributors to drug errors. This report discusses how name and label similarities degrade care, and the actions organizations and individual practitioners can take to mitigate the potential of LASA medication errors that cause harm. The authors discuss obstacles and enablers to implementing prevention strategies.

Technology, Education and Safety

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Arnal-Velasco, D, ed. Curr Opin Anaesthesiol. 2023;36(6):649-705.

Adoption of new ideas is necessary to create safety in the perioperative environment. This collection of reviews illustrates relationships and tensions between technology, human factors and safety management that create the sociotechnical system within which technology is used to deliver anesthesia. Topics covered include artificial intelligence, decision making and perioperative deterioration.

Room for resilience: a qualitative study about accountability mechanisms in the relation between work-as-done (WAD) and work-as-imagined (WAI) in hospitals.

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Weenink J-W, Tresfon J, van de Voort I, et al. BMC Health Serv Res. 2023;23:1048.

Promoting resilience across and within healthcare organizations is a key component of Safety-II. This qualitative study involving six teams across three hospitals in the Netherlands found that healthcare professionals, managers, and quality advisors hold differing perspectives regarding the right approach to clinical practices and the importance of certain clinical actions. The authors underscore the importance of team reflections to foster resilience and accountability across all levels within healthcare organizations.

Alarm burden and the nursing care environment: a 213-hospital cross-sectional study.

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Ruppel H, Dougherty M, Bonafide CP, et al. BMJ Open Qual. 2023;12:e002342.

Alarm fatigue can lead to desensitization to safety alerts and threaten patient safety. In this survey of 3,986 registered nurses, the majority (83%) reported alarm fatigue and over half (55%) experienced a situation where an alarm went unchecked despite a patient requiring urgent attention. The researchers found that alarm burden was more common among respondents who rated their hospital’s safety as poor or reported poor work environments.

The benefits and opportunities: engaging patients in identifying and reporting patient safety incidents.

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Pozzobon LD, Rotter T, Sears K. Healthc Manage Forum. 2023;Epub Oct 13.

Patient and caregiver engagement in patient safety can improve individual outcomes and help identify safety threats. This article highlights the advantages of including patients in patient safety event reporting, including broadening the understanding of harm to include psychological and financial harms, identifying contributing factors to harm, and notes several organizational activities where patients and caregiver involvement can be integrated.

Authentic leadership at the Cleveland Clinic: psychological safety in the midst of crisis.

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Porter TH, Peck JA, Bolwell B, et al. BMJ Lead. 2023;7:196-202.

Authentic leadership principles emphasize the influence of positive psychological capacities to foster self-awareness and self-regulated positive behaviors. This qualitative study used podcast transcripts to explore the experiences of senior leadership during the COVID-19 pandemic and the role of authentic leadership principles. The researchers identified several behaviors demonstrating authentic leadership and discuss its influence of psychological safety, particularly during a crisis.

Effect of complementary interventions to redesign care on teamwork and quality for hospitalized medical patients: a pragmatic controlled trial.

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O’Leary KJ, Johnson JK, Williams MV, et al. Ann Intern Med. 2023;Epub Oct 31.

Teamwork is an essential component of ensuring high quality, safe healthcare. This article describes findings from the Redesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study, which evaluated the impact of complementary interventions to redesign unit-based care (unit-based physician teams, nurse-physician co-leadership, interprofessional rounds, performance reports, patient engagement) on interprofessional teamwork and patient outcomes. Findings demonstrate improved teamwork climate scores among nurses (but not physicians), but researchers did not identify a significant impact on patient outcomes.

A study of error reporting by nurses: the significant impact of nursing team dynamics.

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Munn LT, Lynn MR, Knafl GJ, et al. J Res Nurs. 2023;28:354-364.

Nursing team dynamics can influence safety culture and willingness so speak up about errors and safety concerns. This survey of over 650 nurses and nurse managers underscored the importance of leader inclusiveness, safety climate, and psychological safety in cultivating speaking up behaviors among nursing team members.

Preventing nosocomial bloodstream infections (NBSIs) by implementing hospitalwide, department-level, self-investigations: a NBSIs frontline ownership intervention.

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Mudrik-Zohar H, Chowers M, Temkin E, et al. Infect Control Hosp Epidemiol. 2023;44:1562-1568.

Nosocomial infections remain a persistent patient safety issue and can lead to serious patient harm. This article describes one Israeli hospital’s experience using department-level investigations to reduce the incidence of nosocomial bloodstream infections. Study findings demonstrated that department-level investigations coupled with increased staff awareness led to significant reductions in nosocomial bloodstream infections.

Anesthesia workspaces for safe medication practices: design guidelines.

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MohammadiGorji S, Joseph A, Mihandoust S, et al. HERD. 2023;Epub Aug 8.

Well-designed workspaces minimize disruptions and distractions. This review and study describes several important ways to improve the anesthesia workspace in the operating room. Recommendations include demarcating an anesthesia zone with adequate space for equipment and storage and that restricts unnecessary staff travel into and through the zone. Each recommendation includes an illustrative diagram, explains its importance, and offers methods to achieve it.

Detection rates of mild cognitive impairment in primary care for the United States Medicare population.

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Liu Y, Jun H, Becker A, et al. J Prev Alz Dis. 2023;Epub Oct 24.

Persons with dementia are at increased risk for adverse events compared to those without dementia, highlighting the importance of a timely diagnosis. In this study, researchers estimate approximately 20% of primary care patients aged 65 and older are expected to have a diagnosis of mild cognitive impairment or dementia; however, only 8% have received such a diagnosis. Missed diagnosis prevents patients from receiving appropriate care, including newly FDA-approved medications to slow cognitive decline.

Medical students' experiences, perceptions, and management of second victim: an interview study.

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Krogh TB, Mielke-Christensen A, Madsen MD, et al. BMC Med Educ. 2023;23:786.

Medical trainees suffer from "second victim syndrome" (SVS) at rates similar to practicing healthcare professionals but they may not have the same resources to recover. This study of medical students' experiences describes the usual triggers of SVS such as patient harm, but also from negative responses by supervising physicians. Formal instruction and open discussion of SVS can support students' well-being and recovery.

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