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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

Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD |

This perspective discusses high reliability organization principles and their implementation in a variety of healthcare settings. Evidence continues to show adopting high reliability principles improves patient safety, but fully... Read More

David W. Bates, MD, MSc; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD |

David W. Bates, MD, MSc, is the Medical Director for Clinical and Quality Analysis for MGB Healthcare and co-directs the Center for Artificial Intelligence and Bioinformatics in the Learning Healthcare System. He is also a Professor of... Read More

All Clinical Areas (16198)

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Displaying 1 - 20 of 16582 Results
Displaying 1 - 20 of 16582 Results

Institute for Safe Medication Practices: March 2025.

Community pharmacies are common providers of medication delivery that harbor process weaknesses affecting safety. This guidance shares evidence-based steps to address problems such as wrong patient errors and lack of consistent barcode system use in the community setting. New practices highlighted in 2025 focus on weight-based dosing, vaccine preparation and technology use in return-to-stock processes. 
Health Services Safety Investigations Body. 2024-2025
Omitted or delayed medication therapy can contribute to patient discomfort, stress, and harm. This series of reports, to be developed over 2024-2025, examines factors at different points in the medication administration process that contribute to medications not being provided reliably to support safe patient care. The first report in the series covered factors present in NHS emergency departments that influence timely medication administration. The second examines failures and improvement opportunities in anticoagulant medication administration processes.
Bender JA, Thiyagarajan S, Morrish W, et al. J Patient Saf. 2025;21(2):69-81.
Miscommunication is a major contributor to adverse events. This article describes the development of a framework to classify communication errors that contributed to a patient safety incident. Nine types of communication errors were identified. Falls and delays in diagnosis, treatment, or surgery were the most common adverse events related to communication errors.
Prothero MM, Sorhus M, Huefner K. J Nurs Adm. 2024;54(12):664-669.
Nursing leadership plays an important role in establishing a culture of safety. Findings from this cross-sectional survey with 255 nurse leaders highlight the important role of authentic leadership in fostering psychological safety and supporting nurses after serious medical errors. Survey respondents also endorsed the importance of formal support programs, including peer support, education, error analysis, and just culture.
Black GB, Nicholson BD, Moreland J-A, et al. BMJ Qual Saf. 2025;Epub Jan 29.
Patients presenting with non-specific symptoms (NSSs) suggestive of cancer may experience diagnostic delays. In this study with four National Health Service (NHS) NSS cancer pathways teams, researchers identified distinct functions of the team, clustered in pre-testing assessment and information gathering and post-testing interpretation and management. There was wide variation between the sites in referral processing, patient coordination, team communication, and follow up.
Morreim EH. Hous J Health Law Policy. 2025;24:127-165.
Artificial intelligence (AI) systems effect decision-making using a variety of clinical and managerial healthcare data sets. This article explores the potential weaknesses in large administrative databases – weaknesses inherent in data submitted to, and recorded by, humans – which can undermine the accuracy and effectiveness of AI generated information.
Milanesi M, Fiorito R, Caloccia L, et al. BMJ Open Qual. 2025;14(1):e003012.
Integrated care pathways (ICPs) are patient-centered and multidisciplinary. This article describes the development of an audit plan using Tracer methodologies to audit six oncology ICPs at a comprehensive cancer center. This methodology ensured the audit was patient-centered and focused on the patient's journey through several departments and facilities.
Mills PD, Tomolo A, Yackel EE. Jt Comm J Qual Patient Saf. 2024;Epub Dec 20.
Health care is increasingly being provided remotely through telephone, video calls, and remote monitoring. Information on the prevalence and characterization of adverse events associated with telehealth is paramount to improving safety. This study analyzed 145 safety incidents related to telehealth at the VHA. The largest category was delays in care, and 90% of incidents resulted in no harm. Just over one-third were associated with the telehealth platform itself.
Rochford A. Future Healthc J. 2024;11(4):100205.
Medication errors and adverse drug events (ADEs) impact a significant number of patients every year. This article describes ongoing challenges (e.g., workforce limitations, polypharmacy) faced by safe prescribing and medication administration practices. The authors also highlight best practices and emerging approaches (such as artificial intelligence) that can advance medication and prescribing safety.
Mahajan P, White E, Shaw KN, et al. Acad Emerg Med. 2025;Epub Jan 15.
Electronic triggers and trigger tools are important methods of identifying and studying adverse events, such as missed opportunities for improving diagnosis (MOID). Using three triggers and the Revised Safer Dx Instrument, this study uncovered the frequency, type, causative factors, and severity of diagnostic errors in pediatric emergency departments. The overall frequency of MOID was 2.6% for the entire cohort, the majority of which resulted in patient harm.
Andrew C, Fitzsimons M. APSF Newsletter. 2025;40(1):24-26.
Moving patients from one part of the hospital to another introduces clinical, communication and environmental risks that can reduce safety. This article discusses factors that contribute to patient safety events during intrahospital patient transport and presents a checklist as one mitigation strategy.
Perry K, Jones S, Stumpff JC, et al. J Hosp Med. 2024;Epub Nov 11.
Production pressure and decision fatigue can pose patient safety risks. This scoping review explored how decision fatigue impacts decision-making in inpatient settings. The scoping review, which included 16 studies (primarily focused on emergency and intensive care settings), reported inconsistent findings and did not robustly address the role of clinician, patient, or work factors on decision fatigue.
Martins NRS, Martinez EZ, Simões CM, et al. Int J Qual Health Care. 2025;37(1):mzae114.
Poor handoff communication between teams can hinder safe patient care. This article describes the use of a risk management approach to improve handoffs from the operating room to intensive care. Frontline providers participated in a failure mode effects analysis (FMEA) to identify process failures, causes, and consequences related to handoffs. Participants reported that this approach helped them understand the handoff process beyond their individual roles.
Multi-use Website
Patient Safety Authority.
Small successes can inform and motivate actions leading to sustainable, evidence-based change. This searchable collection of projects initiated in response to event reports supports the spread of good ideas by generating interest in their application to drive patient safety improvement.

US Department of Health and Human Services. 2023-2025. 

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 is a collection of videos in this series of offerings from the Alliance supporting its work to improve safety. The March and April webinars conclude a series of seminars focused on safety culture in health care.

Plymouth Meeting, PA: ECRI; March 2025.

This annual consensus report identifies actions harboring risks that contribute to preventable patient harm. The top ten concerns for 2025 include poor response to patient and family concerns, oversight of artificial intelligence and the "big three" diagnostic errors: cancer, major vascular events and infection. 
Shieu B, Lee Y-W, Epps F, et al. J Gerontol Nurs. 2025;51(3):38-43.
Long-term care residents are at increased risk for experiencing medication administration errors. Using semi-structured phone interviews with 12 nurses, this qualitative study identified several important factors for improving medication safety in nursing home settings, including user-friendly charting systems, improved nurse-to-patient ratios, and customized medication administration interfaces.
Boisvert S, Nelson M, Ross J. J Patient Saf. 2025;21(2):111-117.
Most medication safety research occurs in the inpatient setting, with less focus on ambulatory care. In this analysis of closed malpractice claims, anti-infectants, narcotics, and anticoagulants were identified in nearly half of the claims. Clinical judgment and communication were the most common contributing factors.
Hose B-Z, Handley JL, Biro J, et al. BMJ Qual Saf. 2025;34(2):130-132.
Information on the prevalence of errors in artificial intelligence applications and their impact on the healthcare system provides important guidance on development, implementation, and use. This article describes the development of a classification system for two popular uses of AI in health care: patient-facing large language models (LLM) and ambient digital scribes (ADS). Errors were prevalent in both types, with errors of omission being the most common. Although most errors in the LLM were categorized as having low clinical significance, 25% were categorized as high clinical significance (e.g., omissions of urgent guidance for conditions such as heart attack symptoms).