Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
Additional Filters
1 - 20 of 371
Liukka M, Hupli M, Turunen H. Leadersh Health Serv (Bradf Engl). 2021;Epub Sep 8.
The Hospital Survey on Patient Safety Culture and Nursing Home Survey on Patient Safety Culture were used in one Finish healthcare organization to assess 1) differences in employee perceptions of safety culture in their respective settings, and 2) differences between professionals’ and managers’ views. Managers assessed safety culture higher than professionals in both settings. Acute care patient safety scores were significantly positive in 8 out of twelve domains, compared to only one in long-term care.

Thomas K, Gebeloff R, Silver-Greenberg J. New York Times. September 11, 2021.

Nursing home medication misuse is a contributor to resident harm. This story highlights system influences such as staffing shortages, reporting failures and normalization of prescribing behaviors that coincide with the misuse of antipsychotic medications and overdiagnosis of schizophrenia.

Rockville, MD: Agency for Healthcare Research and Quality; September 9, 2021. PA-21-267. 

This funding opportunity supports large research demonstration and implementation projects applying existing strategies to understand and reduce adverse events in ambulatory and long-term care settings. Projects focused on preventing harm in disadvantaged populations to improve equity are of particular interest. The funding cycle will be active through May 27, 2024.
Wang X, Wilson C, Holmes K. J Gerontol Soc Work. 2021:1-17.
Nursing home residents are especially vulnerable to COVID-19 due to their age and communal living conditions. Using publicly available data for nursing homes in Florida, this study explored the association between nursing home characteristics and COVID-19 cases and deaths. Findings suggest that the likelihood of COVID-19 cases in nursing homes is related to ownership status, facility size and average occupancy rate, rather than quality (as measured by infection prevention and control deficiencies).
Preston-Suni K, Celedon MA, Cordasco’s KM. Jt Comm J Qual Patient Saf. 2021;47(10):673-676.
Presenteeism among healthcare workers – continuing to work while sick – has been attributed to various cultural and system factors, such as fear of failing colleagues or patients. This commentary discusses the patient safety and ethical considerations of presenteeism during the COVID-19 pandemic
Quach ED, Kazis LE, Zhao S, et al. BMC Health Serv Res. 2021;21(1):842.
The safety climate in nursing homes influences patient safety. This study of frontline staff and managers from 56 US Veterans Health Administration community living centers found that organizational readiness to change predicted safety climate. The authors suggest that nursing home leadership explore readiness for change in order to help nursing homes improve their safety climate.
Alexander GL, Madsen RW. J Patient Saf. 2021;17(6):e483-e489.
Information technology (IT) is prevalent across healthcare settings. This study used publicly available nursing home data and a survey on IT sophistication to identify the relationship between nursing home health deficiencies and IT sophistication. Results indicate health deficiencies decreased as IT sophistication increased, suggesting investment in IT could lead to further patient safety benefits in nursing homes.
Van Eerd D, D'Elia T, Ferron EM, et al. J Safety Res. 2021;78:9-18.
Working conditions for healthcare workers can affect patient safety. Conducted at four long-term care facilities in Canada, this study found that a participatory organizational change program can have positive impacts on identifying and reducing musculoskeletal disorder hazards for employees, including slips, trips, falls, and ergonomic hazards. Key factors for successful implementation of the change program include frontline staff involvement/engagement, support from management, and training.

Center for Healthy Aging--New York Academy of Medicine, Yale School of Nursing.

Healthcare-associated infections (HAIs) challenge safety in long-term care. This toolkit highlights multidisciplinary approaches to reducing HAIs and teaching tools focused on distinct audiences across the continuum to share principles and tactics supporting improvement.

ECHO-Care Transitions (ECHO-CT) intends to ensure continuity of care and alleviate the risk of patient safety issues, notably medication errors, occurring because of hospital transition. With funding from the Agency for Healthcare Research and Quality, Beth Israel Deaconess Medical Center (BIDMC) adapted Project Extension for Community Healthcare Outcomes (ECHO) to connect receiving multidisciplinary skilled nursing facility (SNF) teams with a multidisciplinary team at the discharging hospital. Within one week of discharge, hospital providers discuss each patient’s transitional and medical issues with providers at the SNF using videoconferencing technology. The innovation has successfully reduced patient readmission and SNF length of stay.

Damery S, Flanagan S, Jones J, et al. Int J Environ Res Public Health. 2021;18(14):7581.
Hospital admissions and preventable adverse events, such as falls and pressure ulcers, are common in long-term care. In this study, care home staff were provided skills training and facilitated support. After 24 months, the safety climate had improved, and both falls and pressure ulcers were reduced.
Serre N, Espin S, Indar A, et al. J Nurs Care Qual. 2021;Epub Jul 15.
Safety concerns are common in long-term care (LTC) facilities. This qualitative study of LTC nurses explored nurses’ experiences managing patient safety incidents (PSI). Three categories were identified: commitment to resident safety, workplace culture, and emotional reaction. Barriers and facilitators were also discussed.

The MOQI seeks to reduce avoidable hospitalization among nursing home residents by placing an advanced practice registered nurse (APRN) within the care team with the goal of early identification of resident decline. In addition to the APRN, the MOQI involves nursing home teams focused on use of tools to better detect acute changes in resident status, smoother transitions between hospitals and nursing homes, end-of-life care, and use of health information technology to facilitate communication with peers. As a result of the innovation, resident hospitalizations declined. Funding for this innovation was originally provided to the University of Missouri via a Centers for Medicare & Medicaid Services (CMS) demonstration grant. Given the success of the innovation, when the grant funding expired, the model and lessons learned from the initiative were transferred to NewPath Health Solutions, LLC, to ensure continued dissemination.

Baughman AW, Triantafylidis LK, O'Neil N, et al. Jt Comm J Qual Patient Saf. 2021;47(10):646-653.
Medication reconciliation is the process of reviewing a patient’s medication list for discrepancies and safety. Patients in nursing homes are at increased risk for medication discrepancies due to complexity of care and frequent transitions of care. By using Healthcare Failure Mode and Effect Analysis (FMEA), researchers uncovered several factors that contribute to medication discrepancies. Interventions to improve medication safety can be targeted to one or more of the contributing factors.
Werner NE, Rutkowski RA, Krause S, et al. Appl Ergon. 2021;96:103509.
Shared mental models contribute to effective team collaboration and communication. Based on interviews and thematic analysis, the authors explored mental models between the emergency department (ED) and skilled nursing facility (SNF). The authors found that these healthcare professionals had misaligned mental models regarding communication during care transitions and healthcare setting capability, and that these misalignments led to consequences for patients, professionals, and the organization.

Rockville, MD: Agency for Healthcare Research and Quality; June 2021.

The use of antibiotics should be monitored to reduce the potential for infection in care facilities. This toolkit outlines offers a methodology for launching or invigorating an antibiotic stewardship program. Designed to align with four time elements of antibiotic therapy, its supports processes that enable safety for nursing home residents.
Adams KT, Pruitt Z, Kazi S, et al. J Patient Saf. 2021;Epub May 20.
It is important to consider unintended consequences when implementing new tools, such as health information technology (HIT). This study reviewed 2,700 patient safety event reports to identify the type of medication error, the stage in the process in which the error occurred, and how HIT usability issues contributed to the errors. Errors in dosing were the most frequent type, and occurred during ordering or reviewing. Most errors described usability issues which should be considered and addressed to improve medication safety.
Manias E, Bucknall T, Hutchinson AM, et al. Expert Opin Drug Saf. 2021:1-19.
Medication errors are a common cause of preventable harm in long-term care facilities. This systematic review explored how residents and families engage in medication management in aged care facilities. Factors hindering effective engagement included insufficient communication between residents, families, and providers; families’ hesitation about decision making; and lack of provider training.
Guo W, Li Y, Temkin-Greener H. J Am Med Dir Assoc. 2021;Epub May 25.
This study examined the association between patient safety culture (PSC) and community discharge of long-term care (LTC) residents.  Results show that two domains of PSC- teamwork and supervisor expectations and actions regarding patient safety- are significantly associated with increased likelihood of discharge to a community setting. Focusing on these domains to improve patient safety culture may also increase community discharge rates. 
Shafiee Hanjani L, Hubbard RE, Freeman CR, et al. Intern Med J. 2021;51(4):520-532.
Cognitively impaired older adults living in residential aged care facilities (RACF) are at risk of adverse drug events related to potentially inappropriate polypharmacy. Based on telehealth visits with 720 RACF residents, 66% were receiving polypharmacy, with cognitively intact residents receiving significantly more medications than cognitively impaired residents. Overall, 82% of residents were receiving anti-cholinergic medications which should be avoided in this population. Future interventions and research should pay particular attention to the prescribing of these medications.