The PSNet Collection: All Content
Search All Content
- Clinical Guideline(2)
- Journal Article(227)
- Newspaper/Magazine Article(27)
- Patient Safety Innovations(1)
- Patient Safety Primers(3)
- Perspectives on Safety(7)
- Press Release/Announcement(4)
- Special or Theme Issue(9)
- WebM&M Cases(31)
- Web Resource(11)
- Care Coordination(4)
- Communication Improvement(66)
- Computerized Decision Support(14)
- Computerized Provider Order Entry (CPOE)(7)
- Culture of Safety(32)
- Education and Training(45)
- Error Reporting and Analysis(95)
- Human Factors Engineering(54)
- Legal and Policy Approaches(25)
- Logistical Approaches(24)
- Policies and Operations(13)
- Quality Improvement Strategies(79)
- Research Directions(14)
- Specialization of Care(9)
- Technologic Approaches(51)
- Transparency and Accountability(6)
- Alert fatigue(1)
- Device-Related Complications(12)
- Diagnostic Errors(141)
- Discontinuities, Gaps, and Hand-Off Problems(45)
- Failure to rescue(2)
- Fatigue and Sleep Deprivation(4)
- Identification Errors(14)
- Interruptions and distractions(9)
- Medical Complications(15)
- Medication Safety(18)
- MRI safety(21)
- Nonsurgical Procedural Complications(61)
- Psychological and Social Complications(16)
- Second victims(1)
- Surgical Complications(11)
- Transitions of Care(2)
Satariano A, Metz C. New York Times. March 5, 2023.
Harolds JA, Harolds LB. Clin Nucl Med. 2015–2023.
Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.
Dr. Pascale Carayon, PhD, is a professor emerita in the Department of Industrial and Systems Engineering and the founding director of the Wisconsin Institute for Healthcare Systems Engineering (WIHSE). Dr. Nicole Werner, PhD, is an associate professor in the Department of Health and Wellness Design at the Indiana University School of Public Health-Bloomington. We spoke with both of them about the role of human factors engineering has in improving healthcare delivery and its role in patient safety.
Appropriate follow-up of incidental abnormal radiological findings is an ongoing patient safety challenge. Inadequate follow-up can contribute to missed or delayed diagnosis, potentially resulting in poorer patient outcomes. This study describes implementation of an electronic health record-based referral system for patients with incidental radiologic finding in the emergency room.
A 47-year-old man underwent a navigational bronchoscopy with transbronchial biospy under general anesthesia without complications. The patient was transferred to the post-acute care unit (PACU) for observation and a routine post-procedure chest x-ray (CXR). After the CXR was taken, the attending physician spoke to the patient and discussed his impressions, although he had not yet seen the CXR. He left the PACU without communicating with the bedside nurse, who was caring for other patients. The patient informed the nurse that the attending physician had no concerns.
This WebM&M highlights two cases of patient safety events that occurred due to medication dosing related to diagnostic imaging. The commentary highlights the challenges of administering sedation for diagnostic imaging, the use of risk stratification to understand patient risk for oversedation, and strategies for appropriate monitoring and communication.
Jagsi R, Griffith KA, Vicini F, et al for the Michigan Radiation Oncology Quality Consortium. JAMA Oncol. Epub 2022 Apr 21.
J Med Imaging Radiat Oncol. 2022;66(2):165-309.
Moore QT, Walker DA, Frush DP, et al. Radiol Technol. 2022;93(3):255-267.