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

Opioid prescribing for acute pain management in children and adolescents in outpatient settings: clinical practice guideline.

Hadland SE, Agarwal R, Raman SR, et al. Pediatrics. 2024;154:e2024068752.

Acute pain treatment for children in the ambulatory setting is a high-risk activity. This clinical guideline outlines safe... Read More

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

Life of the Mother. How Abortion Bans Lead to Preventable Deaths.

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... Read More

All Clinical Areas (16198)

Displaying 201 - 220 of 16483 Results

Review

A daily dose of communication to improve quality and safety outcomes.

Save to Library

Halm MA. Am J Crit Care. 2024;33(4):305-310.

High-reliability organizations are built on elements that reduce hierarchy, improve communication, and recognize expertise in team members during times of crisis. This summary of the literature explores evidence supporting the use of huddles to enhance transparency and information sharing. It provides a sample structure for HRO huddles at the unit level.

Study

Crowdsourced feedback to improve resident physician error disclosure skills: a randomized clinical trial.

Save to Library

White AA, King AM, D’Addario AE, et al. JAMA Netw Open. 2024;7(8):e2425923.

Open disclosure of errors is increasingly encouraged in health care and emphasized in health profession training. This randomized trial evaluated the effectiveness of video-based communication assessment (VCA) feedback in resident error disclosure skill training. The researchers found that internal medicine and family medicine residents who received individual feedback on simulated error disclosure performance scored significantly higher on subsequent error disclosure assessments, as compared to residents who did not receive feedback.

Review

Care quality and safety in long-term aged care settings: a systematic review and narrative analysis of missed care measurements.

Save to Library

Wang X, Rihari‐Thomas J, Bail K, et al. J Adv Nurs. 2024;Epub Aug 2.

Missed nursing care can lead to lower quality of care and threaten patient safety. This systematic review including 24 articles evaluated methods for measuring missed nursing care in long-term aged care (LTAC) settings. The authors concluded that existing tools are inconsistently applied and lack strong methodologic verification; additional research to develop standardized, validated tools is needed.

Study

Leadership and the high reliability transformation: a qualitative study at Truman VA medical center.

Save to Library

Leonard C, Gilmartin HM, Starr LM, et al. J Healthc Risk Manag. 2024;44(1):17-23.

Like many health care organizations, the Veterans Health Administration (VHA) is working towards becoming a high-reliability organization (HRO). In this qualitative study, researchers interviewed 14 current and past leaders involved in HRO transformation at the Harry S. Truman Memorial Veterans' Hospital. Leaders identified three key strategies for achieving high reliability: (1) consistent communication from leadership and modeling of HRO principles, (2) empowering frontline staff to make changes and fail, and (3) hiring and training team members in alignment with organizational culture and HRO values.

Study

Understanding the challenges and successes of implementing 'hybrid' interventions in healthcare settings: findings from a process evaluation of a patient involvement trial.

Save to Library

Hampton S, Murray J, Lawton R, et al. BMJ Qual Saf. 2024;Epub Aug 6.

Transitions of care between the hospital and home can jeopardize patient safety for a myriad of reasons, such as communication gaps and poor care coordination. This article evaluates the implementation of hybrid “Your Care Needs You” (YCNY) intervention in the UK’s National Health Services (NHS), which aims to improve the safety of care transitions from hospital to home by supporting patients in (1) managing health and well-being, (2) medication management, (3) completing activities of daily living, and (4) anticipating needs and escalating care. Qualitative evaluations and observations found that YCNY goals resonated with patients, but that implementation was often hampered by time constraints and understaffing.

Study

Medical malpractice litigation and daylight saving time.

Save to Library

Gao C, Lage C, Scullin MK. J Clin Sleep Med. 2024;20(6):933-940.

Sleep deprivation or changes to circadian rhythm (such as those introduced by daylight savings time, or DST) can hinder the delivery of safe health care. In this analysis of 288,432 malpractice claims between January 1990 and September 2018, researchers found that the spring transition to DST was not associated with higher severity patient safety incidents, but that events occurring during the 7-8 months of DST were more severe compared to the 2-4 months of standard time.

Study

Patients' perceptions of using technology for self-reporting cancer medication safety events from home.

Save to Library

Gahn K, Hwang M, Cho Y, et al. Stud Health Technol Inform. 2024;315:398-403.

Patients with higher medication complexity, such as patients with cancer, are particularly vulnerable to medication safety events (MSEs). This qualitative study with patients with breast, prostate, lung, and colorectal cancer identified several barriers to the use of technology for MSE self-reporting, such as limited access to technology and low confidence in using technology.

Study

Exploring the impact of pharmacist-supported medication reviews in dementia care: experiences of general practitioners and nurses.

Save to Library

Carlqvist C, Ekstedt M, Lehnbom EC. BMC Geriatr. 2024;24(1):520.

Polypharmacy in older adults, particularly those with dementia, can increase the risk of patient safety events. This qualitative study evaluated whether integrating pharmacists into care teams at special housing for older adults in Sweden improved medication safety. Findings from semi-structured interviews and content analysis revealed that pharmacists are perceived to be important members of the care team, but communication barriers within teams hinders medication safety.

Study

Near-miss and maternal sepsis mortality: a qualitative study of survivors and support persons.

Save to Library

Bauer ME, Perez SL, Main EK, et al. Eur J Obstet Gynecol Reprod Biol. 2024;299:136-142.

Delayed diagnosis and management of sepsis can lead to significant patient harm. This qualitative study explored patient perspectives about near-miss events and deaths due to maternal sepsis. The focus groups and interviews identified four key issues important for future quality improvement efforts: insufficient awareness of sepsis warning signs, atypical symptoms, dismissal of concerns leading to delayed diagnosis, and difficulty accessing follow-up care.

Review

Minimization of occurrence of retained surgical items using machine learning and deep learning techniques: a review.

Save to Library

Abo-Zahhad M, El-Malek AHA, Sayed MS, et al. BioData Min. 2024;17(1):17.

Retained surgical items (RSIs) remain a persistent patient safety problem. This review examined the use of machine learning (ML) and deep learning (DL) tools to support RSI prevention and detection and how these applications can be integrated with existing safety practices in perioperative care.

Toolkit

TeamSTEPPS for Diagnosis Improvement.

Save to Library

Rockville, MD: Agency for Healthcare Research and Quality; June 2024.

The recognition of diagnosis as a team activity is energizing new diagnostic process initiatives. Building on the established TeamSTEPPS® principles, this new TeamSTEPPS course includes seven training modules, team and knowledge assessment tools, and implementation guidance to develop or enhance communication across the care team to improve the accuracy and timeliness of diagnosis. Training opportunities for August, September, and October 2024 are now available for registration.

Study

Hospital rating organizations' quality and patient safety scores: analysis of result discrepancies.

Save to Library

Badr S, Nahle T, Rahman S, et al. J Gen Intern Med. 2024;Epub Jul 19.

Patients and families can look at various rating systems to compare hospitals, nursing homes, and other healthcare providers. This study compared ratings of four national hospital rating organizations: Hospital Compare, Healthgrades, The Leapfrog Group, and US News and World Report. The results showed discordance between hospital ratings on several important overall and condition-specific measures, potentially causing confusion for patients seeking care.

Study

Feedback loop failure modes in medical diagnosis: how biases can emerge and be reinforced.

Save to Library

Aikens RC, Chen JH, Baiocchi M, et al. Med Decis Making. 2024;44(5):481-496.

Large electronic health record- or population-based datasets form the basis for many diagnostic error studies. This article raises the issue of data-driven feedback loop failures which occur when disease incidence, presentation, and risk factors are misunderstood in research and, therefore, future medical practice. For example, men presenting with "classic" symptoms of heart attack are more frequently targeted for evaluation than women with "atypical" symptoms, thereby resulting in underdiagnoses of heart attack in women and underrepresentation in the evidence base.

Review

Medication errors in emergency departments: a systematic review and meta-analysis of prevalence and severity

Save to Library

Nguyen PTL, Phan TAT, Vo VBN, et al. Int J Clin Pharm. 2024;46(5):1024-1033.

The fast-paced and complex environment of the emergency department (ED) can threaten patient safety. In this meta-analysis, the pooled prevalence of medication errors in the ED was 22%. The researchers estimated that 36% of patients experienced a medication error in the ED, with about 43% of these errors being potentially harmful but without leading to death.

Study

Improving departmental psychological safety through a medical school-wide initiative

Save to Library

Porter-Stransky KA, Horneffer-Ginter KJ, Bauler LD, et al. BMC Med Educ. 2024;24(1):800.

Psychological safety is when team members feel comfortable speaking up without fear of negative consequences. This study evaluated a multi-year medical school-wide initiative to improve psychological safety through education, departmental champions, and leadership training. The researchers identified significant improvements in employees’ perceptions of psychological safety at the departmental level but not institution-wide.

United States Meeting/Conference

Diagnostic Excellence 2024 (DEX24).

Save to Library

University of Minnesota, UCSF Coordinating Center for Diagnostic Excellence. University of Minnesota Masonic Children's Hospital. Minneapolis, MN. October 13-14, 2024.

Achieving diagnostic excellence is a key objective for those in the patient safety community. The Diagnostic Excellence 2024 (DEX24) meeting, jointly sponsored by the University of Minnesota and the UCSF Coordinating Center for Diagnostic Excellence, will highlight avenues to advance diagnostic excellence, including how artificial intelligence (AI) can be used to further diagnostic excellence in research, education, and practice.

Meeting/Conference Proceedings

The Impact of Artificial Intelligence (AI) on the Safety of Patients.

Save to Library

Institute for Healthcare Improvement. August 19, 2024.

Artificial intelligence (AI) is rapidly expanding across a wide range of clinical and administrative health care functions. This webinar examined general AI implementation recommendations and examine its potential impact on the safety of clinical decision support, consumer-facing automated support tools, and records support.

Special or Theme Issue

Healthcare Simulation in Nursing Practice.

Save to Library

Watts PI. Nurs Clin North Am. 2024;59(3):345-510.

Simulation is an established method to examine nursing process resilience and develop non-technical skills to improve safety. Articles in this special issue cover topics such as team communication improvement, debriefing practices, and simulation training experience design.

Audiovisual

First with Kids: Medication Errors.

Save to Library

First L. NBC5. August 1, 2024.

Medication mistakes involving children are common. This news segment provides suggestions for parents to help improve the safety of medication use with children at home. Tactics emphasized include caution regarding use of household spoons to dose liquid medications.

Study

Stakeholder perceptions of and attitudes towards problematic polypharmacy and prescribing cascades: a qualitative study.

Save to Library

Jennings AA, Doherty AS, Clyne B, et al. Age Ageing. 2024;53(6):afae116.

An unintentional prescribing cascade occurs when a medication side effect is misinterpreted as a new symptom resulting in the initiation of a new medication. Interviews were conducted with patients, caregivers, physicians, pharmacists, and other experts for their perspectives on prescribing cascades in older adults. Adverse drug events, and therefore prescribing cascades, were accepted as unavoidable for older adults taking multiple medications. Clinicians felt challenged when balancing risks and benefits of further prescribing. None of the stakeholder groups felt like they had adequate information for a safe medication reconciliation which presents a missed opportunity to identify and stop prescribing cascades.

Clinical Areas

Latest by Clinical Areas

All Clinical Areas (16198)

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Clinical Areas

Latest by Clinical Areas

All Clinical Areas (16198)

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site

Submit Your Training

Continue as a Guest

Continue Logged In

Submit Your Training

Continue as a Guest

Continue Logged In

New Users to the PSNet site

Submit Your Toolkit

Continue as a Guest

Continue Logged In

Submit Your Toolkit

Continue as a Guest

Continue Logged In

New Users to the PSNet site

Submit Your WebM&M Case

Continue as a Guest

Continue Logged In

Submit Your WebM&M Case

Continue as a Guest

Already have a PSNet

Account?

New Users