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.

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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.

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... Read More

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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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.

Inappropriate prescribing to older patients by nurse practitioners and primary care physicians.

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Huynh J, Alim SA, Chan DC, et al. Ann Intern Med. 2023;Epub Oct 14.

Access to primary care is becoming more challenging, in part due to physicians leaving the field. Twenty-nine states have expanded nurse practitioner (NP) autonomy to increase access. This study compares potentially inappropriate prescribing practices between NPs and primary care physicians (PCP). In the study population, adults aged 65 and older, NPs and PCPs had nearly identical rates of potentially inappropriate prescribing. The authors encourage focusing on improving prescribing practices among all prescribers instead of working to limit prescribing to physicians.

Validation of a reduced set of high-performance triggers for identifying patient safety incidents with harm in primary care.

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Garzón González G, Alonso Safont T, Conejos Míquel D, et al. J Patient Saf. 2023;19:508-516.

Retrospective chart review is the standard for estimating prevalence of adverse events manual review of the electronic health record (EHR) is resource intensive. This study describes the construction and validation of electronic trigger set, TriggerPrim, to rapidly identify charts with potential adverse events in primary care. The resulting set has five triggers: ≥3 appointments in a week at the PC center, hospital admission, hospital emergency department visit, prescription of major opioids, and chronic benzodiazepine treatment in patients 75 years or older. Use of TriggerPrim reduced time in the EHR by half.

Viewpoint: Patient safety in primary care - patients are not just a beneficiary but a critical component in its achievement.

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Kavanagh KT, Cormier LE. Medicine (Baltimore). 2023;102:e35095.

Primary care plays an important role in identifying, avoiding and mitigating patient safety issues. This report highlights several patient safety priorities and how small (<10 providers) primary care practices can promote safe practice and outcomes for their patients.

Implementing a safer and more reliable system to monitor test results at a teaching university-affiliated facility in a family medicine group: a quality improvement process report.

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Dorimain M-V, Plouffe-Malette M, Paquette M, et al. BMJ Open Qual. 2023;12:e002291.

Laboratory tests are an integral part of diagnosing illness and injury, but system issues can result in the delayed communication of results to patients. This article describes use of the AHRQ toolkit Improving Your Office Testing Process to implement new testing and communication procedures. As an academic family practice clinic, an important first step was allowing residents to order tests and receive results in their own name instead of through an attending physician, which can cause delays in communication to patients. Providers and patients were satisfied with the new process.

Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising.

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Young RA, Gurses AP, Fulda KG, et al. BMJ Open Qual. 2023;12:e002350.

Improving medication safety in ambulatory care settings is a patient safety priority. This qualitative study with primary care teams across four sites in the southwestern United States explored approaches to improving medication safety. Respondents emphasized the importance of customization and individualization (e.g., simplifying medication regimens for certain patients) and described how the principles of high reliability can help teams anticipate and respond to medication safety risks.

Multicomponent pharmacist intervention did not reduce clinically important medication errors for ambulatory patients initiating direct oral anticoagulants.

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Kapoor A, Patel P, Mbusa D, et al. J Gen Intern Med. 2023;Epub Sep 27.

Pharmacists are frequently involved in medication reviews for hospitalized patients prescribed direct oral anti-coagulants (DOAC). This randomized controlled study explored pharmacist involvement with patients prescribed DOAC in ambulatory care. The intervention included up to three phone calls, electronic health record communication with the prescriber, and recommendations for lab work. After 90 days, there were no differences in clinically important medication errors between groups.

Identifying and prioritizing educational content from a malpractice claims database for clinical reasoning education in the vocational training of general practitioners.

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van Sassen CGM, van den Berg PJ, Mamede S, et al. Adv Health Sci Educ Theory Pract. 2023;28:893-910.

Improving clinical reasoning is an important component of medical education. Using a medical malpractice claims database, researchers in this study reviewed 50 conditions identified 15 priority conditions that can be used to improve clinical reasoning education for general practitioners. The conditions represent common (e.g., eye infection), complex common (e.g., renal insufficiency, cardiovascular disease, cancer), and complex rare conditions (e.g., ectopic pregnancy) and often demonstrate atypical presentations or complex contextual factors important for diagnostic reasoning.

Clinician well-being assessment and interventions in Joint Commission-accredited hospitals and federally qualified health centers.

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Longo BA, Schmaltz SP, Williams SC, et al. Jt Comm J Qual Patient Saf. 2023;49:511-520.

Supporting and improving clinician well-being has long been a safety focus and received renewed focus during the COVID-19 pandemic. This study sought to understand efforts undertaken to support clinicians’ well-being in Joint Commission-accredited hospitals and Federally Qualified Health Centers (FQHC). Only half of responding hospitals and FQHCs reported implementing at least one action towards improving clinician well-being (e.g., establishing a wellness committee) and few had implemented a comprehensive approach.

A scoping review exploring the confidence of healthcare professionals in assessing all skin tones.

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Harrison J. Br Paramed J. 2023;8:18-28.

Patients with dark skin tones are not well represented in health education, particularly dermatology, which can result in delayed diagnosis. In this scoping review, thirteen articles were identified assessing the confidence of students and healthcare providers in assessing patients with dark skin tones. Overall, confidence was low but tailored training somewhat improved confidence. The author asserts more research and education is needed outside dermatology, for example, when assessments use terms such as pale, redness, or blue.

Patient and family contributions to improve the diagnostic process through the OurDX electronic health record tool: a mixed method analysis.

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Bell SK, Harcourt K, Dong J, et al. BMJ Qual Saf. 2023;Epub Aug 21.

Patient and family engagement is essential to effective and safe diagnosis. OurDX is a previsit online engagement tool to help identify opportunities to improve diagnostic safety in patients and families living with chronic conditions. In this study, researchers implemented OurDX in specialty and primary care clinics at two academic healthcare organizations and examined the potential safety issues and whether patient/family contributions were integrated into the post-visit notes. Qualitative analysis of 450 OurDX reports found that participants contributed important information about the diagnostic process. Participants with diagnostic concerns were more likely to raise concerns about the diagnostic process (e.g., access barriers, problems with tests/referrals, communication breakdowns), which may represent diagnostic blind spots.

Pediatric Diagnostic Safety: State of the Science and Future Directions.

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Grubenhoff JA, Cifra CL, Marshall T, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication No. 23-0040-5-EF.

Unique challenges accompany efforts to study and reduce diagnostic error in children. This issue brief discusses addressing obstacles associated with testing and care access limitations that affect diagnosis across a variety of pediatric care environments. It also provides recommendations for building capacity to advance pediatric diagnostic safety. This issue brief is part of a series on diagnostic safety.

Understanding and Improving Diagnostic Safety in Ambulatory Care.

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Rockville, MD: Agency for Healthcare Quality and Research; August 22, 2023.

The articulation of diagnostic error in the ambulatory setting is emerging. These newly released funding announcements seek proposals that focus on understanding the factors contributing to diagnostic error and strategies to improve diagnostic safety in the ambulatory care environment. The application deadline for both opportunities has passed.

Perceptions and attitudes of pediatricians and families with regard to pediatric medication errors at home.

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de Dios JG, Lopez-Pineda A, Juan GM-P, et al. BMC Pediatr. 2023;23:380.

Children are at-risk for medication errors in the home setting, but no single database exists to collect these errors. This study compared parent and pediatrician perspectives on home medication safety for children aged 14 and under. Approximately 80% of pediatricians thought parents consulted the internet for information about their child's care and medications, and an equal percent of parents reported consulting their healthcare provider. Both groups reported lack of parental knowledge as the main contributor to medication errors, and most pediatricians supported the idea of a mechanism for collecting parent-reported errors and a learning system to support family engagement in medication error prevention.

Activating pharmacists to reduce the frequency of medication-related problems (ACTMed): a stepped wedge cluster randomised trial.

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Spinks J, Violette R, Boyle DIR, et al. Med J Aust. 2023;219:325-331.

Medication safety in ambulatory care settings is an area of growing concern. This article describes ACTMed (ACTivating primary care for MEDicine safety), a cluster randomized trial set in Australia which intends to improve medication safety in primary care settings. The ACTMed intervention will use health information technology (e.g., clinical indicator algorithms), guideline-based clinical recommendations, shared decision-making, and financial incentives to reduce serious medication-related harm, medication-related hospitalizations, and death.

Healthcare fragmentation, multimorbidity, potentially inappropriate medication, and mortality: a Danish nationwide cohort study.

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Prior A, Vestergaard CH, Vedsted P, et al. BMC Med. 2023;21:305.

System weaknesses (e.g., resource availability, deficiencies in care coordination) threaten patient safety. This population-based cohort study including 4.7 million Danish adults who interacted with primary or hospital care in 2018, found that indicators of care fragmentation (e.g., higher numbers of involved clinicians, more transitions between providers) increased with patient morbidity level. The researchers found that higher levels of care fragmentation were associated with adverse outcomes, including potentially inappropriate prescribing and mortality.

Five new ways to advance diagnostic safety in your clinical practice.

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Bradford A, Goeschel C, Shofer M, et al. Am Fam Physician. 2023;108(1):14-16.

Diagnostic errors are common in the ambulatory environment. This article discusses five tools to help primary care practices implement diagnostic safety improvement strategies. The authors share overarching considerations to support tool implementation including keeping efforts modest and seeing diagnostic safety beyond the clinical realm.

Addressing structural racism in pediatric clinical practice.

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Laster M, Kozman D, Norris KC. Pediatr Clin North Am. 2023;70:725-743.

Structural racism and the resulting negative social determinants of health (SDoH) impact the quality of care that children of color receive. This commentary presents strategies for pediatricians to eliminate structural racism at the system- and organizational-levels such as ensuring access to equitable healthcare facilities, creating an environment of inclusion and respect, and eliminating use of algorithms that include race or ethnicity and result in inequitable treatment.

Identifying failure modes in telemedicine: an instructional needs assessment.

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Monkman H, Kuziemsky C, Homco J, et al. Stud Health Technol Inform. 2023;304:39-43.

Implementation challenges can hinder the safety of telehealth. In this study, medical students used Healthcare Failure Modes and Effect Analysis to identify the causes of failures in telehealth and potential prevention strategies. Four categories of failures were identified: technical issues, patient safety, communication, and social and structural determinants.

The impact of primary care providers' bias on depression screening for lesbian women.

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Sha S, Aleshire M. Health Promot Pract. 2023;24:536-545.

Regular depression screening is recommended for all adults. Using a clinical vignette, the sexuality Implicit Association Test (IAT), and measures of explicit bias, this study examined the relationship of primary care providers' (PCP) bias towards lesbian women and recommendations for depression screening. Providers who recommended screening showed slightly more positive explicit attitudes and slightly lower, though not statistically significant, implicit bias towards lesbian women. However, recommendation rates among all providers were low, at only 38%.

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