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 807

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.
Sajid IM, Parkunan A, Frost K. BMJ Open Quality. 2021;10(3):e001287.
Inappropriate use or overuse of clinical tests such as MRIs can be harmful to patients. This cohort study, including 107 general practitioners across 29 practices, found that only 4.9% of musculoskeletal MRIs were clearly indicated and only 16.7% of results appeared to be correctly interpreted by clinicians, suggesting the potential for significant misdiagnosis and overdiagnosis.
Institute for Healthcare Improvement. September 7–24, 2021
Organization executives influence the success of patient safety improvement. This virtual workshop will meet weekly to highlight how leaders can use assessments, planning, and evidence to improve the safety culture at their organizations.
Mitchell G, Porter S, Manias E. J Adv Nurs. 2021;77(2):899-909.
Oral chemotherapy regimens are complex and may lead to severe adverse drug events. Through ethnographic research, the authors found that the two most important factors in ensuring optimal management of oral chemotherapy are (1) early recognition and appropriate response to side effects and (2) maintenance of safe and effective medication communication.

Quick Safety. March 2021;58:1-2.

The potential exposure to COVID-19 continues to negatively influence patient care seeking activity. This article recommends several strategies for gaining patient trust in the system to keep them safe from exposure which include dedicated spaces for preventative services and proactive encouragement on the importance of screenings such as mammograms.

AHA Training. September 30--November 18, 2021.

Change management skills are important for leaders to implement sustainable safety improvements. This virtual 7-session workshop will use the TeamSTEPPS model to structure organizational approaches for embedding teamwork foundations into processes that support enduring improvement efforts. 
Azam I, Gray D, Bonnett D et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2021. AHRQ Publication No. 21-0012.
The National Healthcare Quality and Disparities Reports review analysis specific to tracking patient safety challenges and improvements across ambulatory, home health, hospital, and nursing home environments. The most recent update documented improvements in approximately half of the patient safety measures tracked. This set of tools includes summaries drawn from the reports for use in presentations to enhance distribution and application of the data.
Calcaterra SL, Lou Y, Everhart RM, et al. J Gen Intern Care. 2021;36(1):43-50.
Opioid use is an ongoing patient safety concern. This large retrospective cohort study found that patients who received oral or intravenous opioids during an urgent care visit were more likely to receive opioids at discharge, and progress to chronic opioid use
De Brún A, Anjara S, Cunningham U, et al. Int J Environ Res Public Health. 2020;17(22):8673.
Leadership has an important role in promoting a culture of safety and enabling necessary changes to enhance patient safety. This article summarizes the design, pilot testing, and refinement of the Collective Leadership for Safety Culture (Co-Lead) program, which offers a systematic approach to developing collective leadership behaviors to promote effective teamwork and enhance safety culture.
Giap T-T-T, Park M. J Patient Saf. 2021;17(2):131-140.
Patients and families are essential partners in identifying and preventing patient safety events. This meta-analysis found that patient and family involvement interventions can significantly reduce adverse events, decrease hospital length of stay, increase patient safety experiences, and improve patient satisfaction.
Gleason KT, Harkless G, Stanley J, et al. Nurs Outlook. 2021;69(3):362-369.
To reduce diagnostic errors, the National Academy of Medicine (NAM) recommends increasing nursing engagement in the diagnostic process. This article reviews the current state of diagnostic education in nursing training and suggests inter-professional individual and team-based competencies to improve diagnostic safety.
Reeves JJ, Ayers JW, Longhurst CA. J Med Internet Res. 2021;23(2):e24785.
The COVID-19 pandemic has led to an extraordinary increase in the use of telehealth. This article discusses unintended consequences of telehealth and outlines guidance to assist health care providers in determining the appropriateness of a telehealth visit.
Zhou Y, Walter FM, Singh H, et al. Cancers. 2021;13(1):156.
Delays in cancer diagnosis can lead to treatment delays and patient harm. This study linking primary care and cancer registry data found that more than one-quarter of bladder and kidney cancer patients presenting with fast-tract referral features did not achieve a timely diagnosis. These findings suggest inadequate adherence to guidelines intended to help identify patients with high risk of cancer based on the presence of alarm signs and symptoms.

Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021.

Effective integration of health information systems supports decision making and treatment coordination across practice settings. This report examines how gaps in information sharing can affect behavioral health care. The authors discuss the potential for diagnostic improvement through information system connections between primary care and behavioral health programs.
Biquet J-M, Schopper D, Sprumont D, et al. J Patient Saf. 2020;Epub Nov 20.
Few medical humanitarian organizations have patient safety reporting and analysis systems. Interviews with medical and paramedical staff working in international humanitarian organizations expressed high expectations for organizational leadership to establish clear patient safety and medical error management policies.  
Chaudhry H, Nadeem S, Mundi R. Clin Orthop Relat Res. 2021;479(1):47-56.
The COVID-19 pandemic has dramatically increased the use of telehealth across various medical specialties.This systematic review did not identify any differences in patient or surgeon satisfaction or patient-reported outcomes with telehealth for orthopedic care delivery as compared to in-person visits.However, the authors note that the included studies did not adequately capture or report safety endpoints, such as complications or missed diagnoses.

Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 5, 2021. Report No. 20-01521-48.

 

This investigation examined care coordination, screening and other factors that contributed to a patient death by suicide shortly after discharge from a Veteran’s Hospital. Event reporting, disclosure and evaluation gaps were identified as process weaknesses to be addressed. 
Erkelens DC, Rutten FH, Wouters LT, et al. J Patient Saf. 2020;Epub Dec 17.
Delays in diagnosis and treatment during after-hours care pose serious threats to patient safety. This case-control study compared missed acute coronary syndrome (ACS) cases to other cases with chest discomfort occurring during out-of-hours services in primary care. Predictors of missed ACS included the use of cardiovascular medication, non-retrosternal chest pain, and consultation of the supervising general practitioner.