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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.

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Displaying 1 - 20 of 16490 Results
Displaying 1 - 20 of 16490 Results

Ehrenwerth J. UptoDate. November 18, 2024.

Operating room fires are never events that, while rare, still harbor great potential for harm. This review discusses settings prone to surgical fire events, prevention strategies, and care management steps should patients be harmed by an operating room fire.
VanGompel EW, Singh L, Carlock F, et al. Ann Fam Med. 2024;22(5):375-382.
Rural care settings face unique challenges in the provision of safe obstetric care. This study explored whether the presence of family medicine (FM) physicians (who are more likely to attend births in rural settings without access to obstetricians or midwives) impacts safety culture and perinatal outcomes. Researchers surveyed 849 clinicians from 39 hospitals in Iowa and found that FM-only hospitals had a lower risk of cesarean deliveries, more support for vaginal birth, and stronger safety culture compared to hospitals with both FM physicians and obstetricians.
Li LZ, Yang P, Singer SJ, et al. JAMA Netw Open. 2024;7(11):e2443059.
Nurse burnout increased during the pandemic and remains prevalent. This review sought to determine the association between nurse burnout and patient safety, patient satisfaction, and quality of care. Nurse burnout increased over time and was negatively associated with these factors. The association between the subcomponents of burnout (e.g., safety culture, emotional exhaustion, and depersonalization) and lower health care quality, safety and patient satisfaction is also presented.
Faugno E, Galbraith AA, Walsh KE, et al. BMJ Qual Saf. 2024;Epub Nov 4.
Historically, underserved racial and ethnic populations have been disproportionately affected by delayed diagnosis. In this review of quantitative studies conducted in the US, patients and caregivers in underserved communities reported several factors contributing to delayed diagnosis. Socioeconomic and sociocultural factors included healthcare avoidance, stigma, and distrust in the healthcare system. Health system factors included poor organizational health literacy and provider-related factors such as cognitive biases. There was a lack of research on diagnosis of chronic conditions, and no studies focused on Asian Americans and Pacific Islanders.
Rockville, MD: Agency for Healthcare Research and Quality; 2024. AHRQ Pub. No. 24-0088
Medication safety is a persistent challenge across health care. This NPSD Chartbook represents a comprehensive look at reported medication and other substance events, outlining data such as when in the process errors occur, human contributors to incidents and percentages of these events resulting in patient harm. The Chartbook identifies patterns in medication or other substance-related patient safety concerns and provides insights on how to mitigate related patient safety risks to reduce harm nationally.
Terry K. WebMD. November 11, 2024;
Patients are partners in health care and can inform actions to identify a quick, accurate diagnosis and receive the care they need. This article introduces why diagnostic errors happen, commonly misdiagnosed conditions, and strategies for patients to participate in the process to ensure it is safe and effective.
White AA, Gallagher TH, Osinska PH, et al. Ann Intern Med. 2024;Epub Nov 5.
Concerns have been raised about the need to assess the clinical skills of aging physicians. This mixed-methods study of 21 physician leaders explored perspectives about mandatory competency screening of late-career physicians (those working beyond age 65 to 75) across 18 healthcare organizations in the United States. Findings suggest that competency assessment policies are all rooted in ensuring patient safety but vary in testing requirements, funding, decision-making processes, and appeal procedures.
Metersky ML, Rodrick D, Ho S-Y, et al. JAMA Netw Open. 2024;7(11):e2442936.
Previous studies have found that the COVID-19 pandemic threatened patient safety due to several factors, including staffing and equipment shortages. This study of Medicare beneficiaries found that higher COVID-19 hospital burden was associated with a 23% higher risk of in-hospital adverse events among patients with and without COVID-19.
Lang Y, Chen K-Y, Zhou Y, et al. Interact J Med Res. 2024;13:e58635.
Patient participation in their own care is promoted as an important safety strategy. In this study, participants were asked to rate the importance and reasonableness of eight safety behaviors promoted by healthcare professionals: bringing medications to office visits, confirming medications at home, managing medication refills, using patient portals, organizing medications, checking medications, getting help, and knowing medications. Confirming medications was rated as the most important behavior, and knowing medications was rated as most reasonable. Using patient portals was rated as lowest in importance and reasonableness. Participants 65 and older reported higher importance and reasonableness of all eight safety behaviors than younger participants.
Hallett N, Dickinson R, Eneje E, et al. Int J Nurs Stud. 2024;161:104923.
Mental health inpatients are a vulnerable population and have reported negative experiences while receiving inpatient psychiatric care. This systematic review highlights adverse or negative experiences reported by current or former inpatients. Across 111 studies, patients reported an imbalance of power, feeling traumatized or retraumatized, and poor coordination during care transitions.
Best NC, Nichols AO, Pierre-Louis B, et al. J Sch Nurs. 2024;40(5):504-513.
As non-healthcare settings, schools face unique challenges ensuring medication safety. In this longitudinal analysis of medication administration in North Carolina public schools (elementary, middle, and high schools), the number of medication errors and corrective action plans increased over time (2012-2018). Results indicate that medication errors increased when there were more schools in the district for nurses to cover. Only half of school nurses held a national certification in school nursing.
Barabucci G, Shia V, Chu ES, et al. NEJM AI. 2024;1(11):AIcs2400502.
Collective intelligence (e.g., collaboration of multiple providers to come to a final diagnosis) has been shown to produce a more accurate diagnosis than even the group’s most senior member. This study applied methods of collective intelligence to four large language models (LLM). The collective diagnosis was more accurate than individual LLMs, even when the highest performing LLM was removed. The authors suggest aggregating diagnoses from multiple LLMs may increase clinician trust in the response and mitigate reliance on a sole LLM or vendor.
Baldwin CA, Krumm AM. AORN J. 2024;120(3):144-154.
The use of peer messengers to provide feedback regarding unprofessional behavior has been shown to be an effective way to improve the work environment, transparency, and accountability. This article describes critical elements for successful implementation of a peer messenger program as part of the Coworker Observation Reporting System. Requirements include socializing the concept and aligning behavioral expectations with the organization's norms or credo and selecting respected informal leaders as messengers.
Adkins S, Alta’any R, Brar K, et al. J Med Educ Curric Dev. 2024;11:23821205241272358.
Many physicians report making at least one error during their careers, therefore coping with errors is an important skill for them to learn. In this intervention, family medicine residents attended three 1-hour didactic sessions featuring guided reflection following mentor storytelling, small group discussion, role play, and self-reflection. Self-efficacy and awareness increased following the intervention but did not reach statistical significance.
Institute for Healthcare Improvement. February 5-6, 2025, 12:00-4:00 PM (eastern).
This online class prepares individuals to apply for the Institute for Healthcare Improvement patient safety certification program. The on-demand or live sessions cover key patient safety concepts to enhance participants' knowledge about safety culture, systems thinking, leadership, risk identification and analysis, information technology, and human factors. 
International Meeting/Conference
Armstrong Institute for Patient Safety and Quality. January 28 and 30, 2025.
Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model. 
Multi-use Website
Leapfrog Group
Drawing from data reported by the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services (CMS), this website provides grades for hospitals in the United States based on their safety. The Fall 2024 hospital safety grade results document improvements in healthcare associated infections, hand hygiene and medication safety scores. 
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).
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.