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Hallvik SE, El Ibrahimi S, Johnston K, et al. Pain. 2022;163:83-90.
Opiates are a high-risk medication due to the potential for adverse events including misuse and overdose. This study examined whether dose reduction or discontinuation after high-dose chronic opioid therapy is associated with suicide, overdose, or other adverse events. In this cohort of Oregon Medicaid recipients, discontinuation increased the risk for suicide or opioid-related adverse events. Patients with stable or increasing doses had an increased risk of overdose.
Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21:139.
Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.
Gandhi TK. Jt Comm J Qual Patient Saf. 2022;48:61-64.
Families and caregivers play an important role in ensuring patient safety. At the start of the COVID-19 pandemic and, to a lesser extent, during surges, family and caregiver visitation was severely restricted. This commentary advocates reassessing risks and benefits of restricted visitation, both during the pandemic and beyond.
Linzer M, Neprash HT, Brown RL, et al. Ann Fam Med. 2021;19:521-526.
Using data from the Healthy Work Place trial, this study explored characteristics associated with high clinician and patient trust. Findings suggest that trust is higher when clinicians perceived their organizational cultures as emphasizing quality, communication and information, cohesiveness, and value alignment between clinicians and leaders.
Lo L, Rotteau L, Shojania KG. BMJ Open. 2021;11:e055247.
Situation, Background, Assessment, Recommendation (SBAR) is a mnemonic technique used to avoid communication failures during handoffs. This systematic review found that fidelity with SBAR is highest in classroom settings, but that studies in clinical contexts either did not achieve sufficient improvements in fidelity or did not assess fidelity.
Montero-Odasso MM, Kamkar N, Pieruccini-Faria F, et al. JAMA Netw Open. 2021;4:e2138911.
Fall prevention in healthcare settings is a patient safety priority. This systematic review found that most clinical practice guidelines provide consistent recommendations for fall prevention for older adults. Guidelines consistently recommend strategies such as risk stratification, medication review, and environment modification.

Newcastle upon Tyne, UK: Care Quality Commission; September 2021.

The safety of maternity care is threatened by inequity. This report analyzes a set of United Kingdom investigation reports to identify issues affecting maternity care to determine their prevalence elsewhere in the system. Problems identified include poor leadership and teamwork, as well as learning and cross-service collaboration.
Institute for Healthcare Improvement. April 6 - June 15, 2022.
Burnout among health care workers negatively affects system improvement. This webinar series will highlight strategies to establish a healthy work environment that strengthens teamwork, staff engagement, and resilience. Instructors include Dr. Donald Berwick and Derek Feeley.
Fontil V, Pacca L, Bellows BK, et al. JAMA Cardiol. 2022;7:204-212.
Racial and ethnic inequities are increasingly being linked to health disparities. This study of more than 16,000 patients explored the association between race and ethnicity and blood pressure control. Findings suggest racial and ethnic inequities in treatment intensification may be associated with more than 20% of observed racial or ethnic disparities in blood pressure control.
Wallis CJD, Jerath A, Coburn N, et al. JAMA Surg. 2022;157:146-156.
Gender, racial, and ethnic disparities in healthcare can adversely impact patient safety and lead to poor outcomes. This retrospective study examined surgeon-patient sex discordance and perioperative outcomes among adult patients in Ontario, Canada, undergoing common elective or emergent surgical procedures from 2007 to 2019. Among 1.3 million patients, sex discordance between surgeon and patient was associated with a significant increased likelihood of adverse perioperative outcomes, including death. Subgroup analyses indicate that this relationship is driven by worse outcomes among female patients treated by male surgeons.
McGaughey J, Fergusson DA, Van Bogaert P, et al. Cochrane Database Syst Rev. 2021;11:CD005529.
Rapid response systems (RRS) and early warning systems (EWS) are designed to detect patient deterioration and prevent cardiac arrest, transfer to the intensive care unit, or death. This review updates the authors’ review published in 2007. Eleven studies representing patients in 282 hospitals were reviewed to determine the effect of RRS or EWS on patient outcomes.
Anand TV, Wallace BK, Chase HS. BMC Geriatr. 2021;21:648.
Older adults, particularly those taking more than one medication, are at increased risk of adverse drug events (ADE). In this study of 6,545 older adult patients who were prescribed at least 3 medications, multidrug interactions (MDI) were identified in 1.3% of medication lists. Psychotropic medications were the most commonly involved medication class; the most common serious ADE were serotonin syndrome, seizures, prolonged QT interval, and bleeding.
London, UK: Parliamentary and Health Service Ombudsman.
The National Health Service broadly reports the results of system-level analyses and investigations into trust-specific failures. This publication series provides information about complaints submitted to trusts to track complaints received and responded to, identify common themes, and uncover recurring problems in an effort to enable organizations to improve processes for managing complaints.
Shen L, Levie A, Singh H, et al. Jt Comm J Qual Patient Saf. 2022;48:71-80.
The COVID-19 pandemic has exacerbated existing challenges associated with diagnostic error. This study used natural language processing to identify and categorize diagnostic errors occurring during the pandemic. The study compared a review of all patient safety reports explicitly mentioning COVID-19, and using natural language processing, identified additional safety reports involving COVID-19 diagnostic errors and delays. This innovative approach may be useful for organizations wanting to identify emerging risks, including safety concerns related to COVID-19.
Ciapponi A, Fernandez Nievas SE, Seijo M, et al. Cochrane Database Syst Rev. 2021;11:CD009985.
Medication errors can lead to harm in hospitalized patients including increased length of stay, lower quality of life, increased morbidity, and even death. This review of 65 studies and 110,875 patients examined interventions (primarily medication reconciliation) and their effect on reducing adverse drug events. Findings revealed mostly low to moderate certainty about the effectiveness of medication reconciliation and low certainty on other interventions, emphasizing the importance of research that has greater power and is methodologically sound.
Mital R, Lovegrove MC, Moro RN, et al. Pharmacoepidemiol Drug Saf. 2022;31:225-234.
Accidental ingestion of over-the-counter (OTC) cold and cough medicines (CCMs) among children can result in adverse events. This study used national surveillance data to characterize emergency department (ED) visits for harms related to OTC CCM use and discusses differences by patient demographics, intent of use, and concurrent substance use.

Ruskin KJ, ed. Curr Opin Anaesthesiol. 2021;34(6):720-765

Anesthesia services are high risk despite progress made in the specialty to improve its safety. This special section covers issues that affect anesthesia safety such as critical incident debriefing, human factors, and educational strategies.
Brenner MJ, Boothman RC, Rushton CH, et al. Otolaryngol Clin North Am. 2021;55.
This three-part series offers an in-depth look into the core values of honesty, transparency, and trust. Part 1, Promoting Professionalism, introduces interventions to increase provider professionalism. Part 2, Communication and Transparency, describes the commitment to honesty and transparency across the continuum of the patient-provider relationship. Part 3, Health Professional Wellness, describes the impact of harm on providers and offers recommendations for restoring wellness and joy in work.
Marufu TC, Bower R, Hendron E, et al. J Pediatr Nurs. 2022;62:e139-e147.
Medication errors threaten patient safety and can result in adverse outcomes. This systematic review identified seven types of nursing interventions used to reduce medication administration errors in pediatric and neonatal patients: education programs, medication information services, clinical pharmacist involvement, double checking, barriers to reduce interruptions during drug calculation and preparation, use of smart pumps, and improvement strategies (e.g., checklists, process or policy changes). Meta-analysis pooling results from various types of interventions demonstrated a 64% reduction in medication administration errors.