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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

Language discordance and patient care-Babel.
Huson TA. JAMA Intern Med. 2024;184:1287-1288.

Equitable, safe health care is affected by myriad socioeconomic factors. This commentary describes a near miss involving a mother who was unable to share concerns about her infant’s health due to language... Read More

Technology, Education and Safety.
Harbell MW, ed. Curr Opin Anaesthesiol. 2024;37:666-742.

Despite consummate efforts to improve safety, errors still occur in anesthesiology. This special collection covers a range of topics affecting safe care in the specialty, including pain management, incident reporting,... Read More

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Displaying 1 - 20 of 16483 Results
Displaying 1 - 20 of 16483 Results
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    • Study
    Large language model influence on diagnostic reasoning: a randomized clinical trial.
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    • Goh E, Gallo R, Hom J, et al. JAMA Netw Open. 2024;7(10):e2440969.
    Large language models (LLM) offer a promising approach to improving diagnostic accuracy. In this study, internal medicine physicians were randomized to use conventional (eg, UpToDate) or conventional plus LLM diagnostic resources to provide a differential and final diagnosis on 4 to 6 clinical vignettes. There was no significant difference in diagnostic performance or time spent per case between conventional and conventional plus LLM groups; LLM alone performed 16% better than the control group.
    Commentary
    Designing an intervention to improve medication safety for nursing home residents based on experiential knowledge related to patient safety culture at the nursing home front line: cocreative process study.
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    • Juhl MH, Soerensen AL, Vardinghus-Nielsen H, et al. JMIR Form Res. 2024;8:e54977.
    Residents of nursing homes (NH) often require multiple medications to treat their chronic conditions. This article describes the co-creation of an intervention to improve medication safety in Danish nursing homes. Unlicensed healthcare personnel who administer the medication (social and healthcare assistants and helpers) and relatives representing NH residents contributed to the design of the intervention. The Safe Medication in Nursing Home Residents (SAME) intervention includes materials to define key roles and responsibilities for healthcare professionals and "medication safety reflexive spaces," a series of facilitated sessions.
    Review
    Improving adverse drug event reporting by healthcare professionals.
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    • Shalviri G, Mohebbi N, Mirbaha F, et al. Cochrane Database Syst Rev. 2024;2024(10):CD012594.
    Adverse drug events (ADE) are common medical errors that can lead to additional healthcare utilization and patient harm. This Cochrane review, including 15 studies with over 62,000 participants, evaluated the effectiveness of interventions to improve ADE reporting. The review found low-certainty evidence that education sessions paired with reminder cards and ADE report forms can significantly improve reporting rates. The review found uncertain or very low-certainty evidence on the effectiveness of other inventions (eg, linking to ADE reporting in the EHR, government regulations with financial incentives).
    Clinical Guideline
    Opioid prescribing for acute pain management in children and adolescents in outpatient settings: clinical practice guideline.
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    • Hadland SE, Agarwal R, Raman SR, et al. Pediatrics. 2024;154(5):e2024068752.
    Acute pain treatment for children in the ambulatory setting is a high-risk activity. This clinical guideline outlines safe opioid prescription practices for children and adolescents. The authors consider inequalities that affect access and timeliness of medication therapy for pain management across ethnic populations.
    Commentary
    CMQCC obstetric sepsis toolkit update: a patient-centered approach to quality improvement.
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    • Main EK, Nath R, Bauer ME. Semin Perinatol. 2024:151976.
    Maternal (or obstetric) sepsis is a leading cause of maternal morbidity and mortality; early identification and rapid response are vital. This report describes a patient-centered approach to diagnosis and treatment of maternal sepsis. Patient educational materials, a checklist to support patients following an adverse event, and standardized approaches to screening and diagnosis are detailed.
    Study
    A virtual breakthrough series collaborative for missed test results: a stepped-wedge cluster-randomized clinical trial.
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    • Zubkoff L, Zimolzak AJ, Meyer AND, et al. JAMA Netw Open. 2024;7(10):e2440269.
    Failure to follow up on test results promptly can lead to delayed diagnoses. This article describes an evaluation of a quality improvement collaborative to improve follow-up on commonly missed test results related to lung and colorectal cancer across 12 VA medical centers. In the study, 11 teams implemented 47 unique interventions, including increased patient engagement through access to test results and preventing EHR notification fatigue. Researchers identified improvements in follow-up rates for abnormal test results at sites with the lowest baseline performance but did not find significant improvements across study sites overall.
    Study
    Could breaks reduce general practitioner burnout and improve safety? A daily diary study.
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    • Hall LH, Johnson J, Watt I, et al. PLoS ONE. 2024;19(8):e0307513.
    Provider burnout has been increasing, particularly since the start of the COVID-19 pandemic, and numerous interventions are being investigated to reduce it. This study used daily diaries from primary care physicians to investigate the association between breaks during the workday and burnout, well-being, and patient safety perceptions. Results indicate that taking a break is associated with lower disengagement that day and lower exhaustion the next day. A break that includes a positive interaction also improves perceptions of patient safety.
    Commentary
    Language discordance and patient care-Babel.
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    • Huson TA. JAMA Intern Med. 2024;184(11):1287-1288.
    Equitable, safe health care is affected by myriad socioeconomic factors. This commentary describes a near miss involving a mother who was unable to share concerns about her infant’s health due to language barriers and the problems her covering physician encountered while advocating for her care.
    Study
    WHO research agenda on the role of the institutional safety climate for hand hygiene improvement: a Delphi consensus-building study.
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    • Tartari E, Storr J, Bellare N, et al. BMJ Qual Saf. 2024;Epub Oct 4.
    Hand hygiene is an important patient safety practice to prevent infection transmission. This article describes a global expert panel charged with developing consensus on research priorities on the role of institutional safety climate in the context of hand hygiene improvement strategies. The panel identified 31 priority research areas. Prioritized topics include the role of safety culture and media in shaping hand hygiene practices, the impact of the built environment, and barriers to, and enablers of, effective leadership support.
    Study
    Detecting clinical medication errors with AI enabled wearable cameras.
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    • Chan J, Nsumba S, Wortsman M, et al. NPJ Dig Med. 2024;7(1):287.
    Medication errors in operating rooms are a persistent patient safety challenge. This article describes training and testing of an AI-enabled wearable camera designed to alert anesthesia providers to medication errors involving a drug vial or syringe. Syringe labels were correctly classified in 98.7% of events, and vials were correctly classified in 99.2%.
    Special or Theme Issue
    Life of the Mother. How Abortion Bans Lead to Preventable Deaths.
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    • Jaramillo C, Surana K, Presser L, et al. ProPublica. 2024:September - November 2024.
    Healthcare policy decisions should be crafted and implemented with consideration of potential unintended consequences that can affect patient safety. This series examines the negative impact of abortion care limitations in the United States. It shares the stories of women and their families who have suffered harm due to lack of access to appropriate treatment.
    Study
    Workplace violence pervasiveness in the perioperative environment: a multiprofessional survey.
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    • Lin DM, Lane-Fall MB, Lea JA, et al. Jt Comm J Qual Patient Saf. 2024;50(11):764-774.
    Physical and nonphysical violence can negatively impact the work environment, increase rates of burnout, and lower perceptions of patient safety. This study details workplace violence experienced and witnessed by perioperative anesthesiologist assistants, certified registered nurse anesthetists, physicians, and registered nurses. More than three-quarters of participants reported having experienced or witnessed some form of workplace violence. Less than half reported satisfaction with how the organization addressed and resolved the situation. The most common sources of workplace violence were the patient or a family member, friend, or physician in the perioperative environment.
    Study
    Adverse events in patients transitioning from the emergency department to the inpatient setting.
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    • Tsilimingras D, Schnipper JL, Zhang L, et al. J Patient Saf. 2024;Epub Sep 27.
    Patients are vulnerable to patient safety events during care transitions between inpatient settings. This study found that over 22% of patients experienced adverse events (AE) during transitions of care between the emergency department (ED) and inpatient care at 2 urban hospitals. The researchers found that most AEs were preventable and commonly involved adverse drug events and diagnostic errors. AEs were more likely to occur among patients with longer ED stays.
    Study
    Enteral nutrition: an underappreciated source of patient safety events.
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    • Citty SW, Chew M, Hiller LD, et al. Nutr Clin Prac. 2024;39(4):784-799.
    Enteral nutrition (EN) therapies are vulnerable to the same types of errors as those occurring in the medication use process (ie, prescribing, transcribing/documenting, dispensing, administering, and monitoring). This study categorized 1,227 EN-related safety events reported to the Joint Patient Safety Reporting (JPSR) system. Three-quarters of reported events were classified as "care management events," eg, incorrect rate or dosage; 31% of errors occurred during administration; and 28% occurred during monitoring.
    Special or Theme Issue
    Technology, Education and Safety.
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    • Harbell MW, ed. Curr Opin Anaesthesiol. 2024;37(6):666-742.
    Despite consummate efforts to improve safety, errors still occur in anesthesiology. This special collection covers a range of topics affecting safe care in the specialty, including pain management, incident reporting, psychological safety, and human factors.
    Review
    Effectiveness of artificial intelligence (AI) in clinical decision support systems and care delivery.
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    • Ouanes K, Farhah N. J Med Syst. 2024;48(1):74.
    Artificial intelligence-based clinical decision support systems (AI-CDSS) hold promise for improving patient outcomes. This review identified 26 articles on the effectiveness of AI-CDSS on patient outcomes. The content analysis revealed 4 themes: early detection and disease diagnosis, enhanced decision-making, medication errors, and clinicians' perspectives. Only 3 of the interventions, which were within the theme of early detection and disease diagnosis, were categorized as highly effective. Patient privacy, data security, and health equity were mentioned as continuing concerns.
    Study
    Focused team engagements to enhance interprofessional collaboration and safety behaviors among novice nurses and medical residents.
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    • Manuel R, Barber A, Kern J, et al. Ped Qual Saf. 2024;9(5):e767.
    Interprofessional communication and teamwork is critical to patient safety. First-year medical and nursing residents participated in team engagement sessions focused on collaboration and safety behaviors through socialization, team communication, and engagement skills. Sessions consisted of a pre-recorded scenario of a safety event resulting in a patient's death followed by a facilitated debrief. Escalation of care, SBAR (situation, background, assessment, recommendation), and “ask a question, make a request, voice a concern” were identified as the top 3 safety/communication techniques that could have changed the outcome of the simulated scenario. Approximately two-thirds of participants perceived lack of confidence and fear of giving the wrong information as barriers to safety/communication techniques.
    Study
    Patient-clinician diagnostic concordance upon hospital admission.
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    • Lam A, Plombon S, Garber A, et al. Appl Clin Inform. 2024;15(4):733-742.
    The failure of a provider to communicate the diagnosis to the patient is a diagnostic error. This communication includes not only telling the patient what their diagnosis is but also ensuring they understand it. In this study, hospitalized patients were asked if "the healthcare team told you the main reason you're in the hospital (your diagnosis) in a way you understand" and their level of confidence in the diagnosis. Just under half of patients reported the same diagnosis as indicated in the electronic health record (EHR), ie, diagnostic concordance. Patients admitted with nonspecific symptoms ("R-codes") and those reporting less confidence in their diagnosis experienced lower diagnostic concordance. Non-English speakers were not included in the study, which the authors recognize as a limitation as this population is particularly vulnerable to suboptimal communication and misdiagnosis.
    Study
    Deficiencies in electronic medical record inpatient list capabilities negatively impact patient safety, resident education, and wellness.
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    • Davalos RA, Aden J, Pluta N, et al. J Surg Educ. 2024;81(11):1533-1537.
    Poor usability results in clinicians spending considerable time working with electronic health records (EHR). Following a change in EHR vendors, residents in 1 orthopedics department were no longer able to automate a pre-populated inpatient list from the EHR; instead, they were required to manually transfer patient information from the EHR to another program, such as Word, prior to rounding and several times throughout the day. Residents were surveyed about the impact of this change on their education, wellness, and patient safety. Interns reported spending an average of 83 minutes per day using the automated list compared to 196 minutes per day with the manual list. Residents in all years reported this change negatively impacted their sleep and education and posed a risk to patient safety.
    Book/Report
    Recommendations but no Action: Improving the Effectiveness of Quality and Safety Recommendations in Healthcare.
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    • Dorset, UK: Health Services Safety Investigations Body; September 2024.
    Recommendations for improvement are only valuable if they are systemically designed and realized in practice. This report explores reasons why progress stalls given robust improvement suggestions submitted to address patient safety. Success can be hampered by various issues, including lack of initiative coordination and transparency, prioritization of actions, discussion of patient impact, and cost evaluation. Collective information and monitoring tools to track suggested actions and progress could enhance implementation of improvement ideas.
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