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101 - 120 of 16981
Groves PS, Bunch JL, Sabin JA. J Clin Nurs. 2021;30:3385-3397.
While many studies have been conducted on implicit bias in healthcare, a gap exists in nurse-specific bias and impact on disparities. This scoping review identified 215 research reports on nurse bias and/or care disparities. Most were descriptive in nature and only 12 included evaluating an intervention designed to reduce nurse-related bias. Recommendations for future research include development and testing of interventions designed to reduce nurse-related bias.
Henderson M, Han F, Perman C, et al. Health Serv Res. 2022;57:192-199.
With the goal of improving allocation of scarce care coordination resources in primary care, this study utilized Medicare fee-for-service claims data to identify risk factors to identify individuals at risk of future avoidable hospital events. Risk factors in six domains were identified: diagnosis, pharmacy utilization, procedure history, prior utilization, social determinants of health, and demographic information.
Hoang R, Sampsel K, Willmore A, et al. CJEM. 2021;23:767-771.
The emergency department (ED) is a complex and high-risk environment. In this study, patient deaths occurring within 7 days of ED discharge were analyzed to determine if the deaths were anticipated or unanticipated and/or due to medical error. Rates of unanticipated death due to medical error were low, however clinicians should consider related patient, provider, and system factors.
Loren DL, Lyerly AD, Lipira L, et al. J Patient Saf Risk Manag. 2021;26:200-206.
Effective communication between patients and providers – including after an adverse event – is essential for patient safety. This qualitative study identified unique challenges experienced by parents and providers when communicating about adverse birth outcomes – high expectations, powerful emotions, rapid change and progression, family involvement, multiple patients and providers involved, and litigious environment. The authors outline strategies recommended by parents and providers to address these challenges.
Phillips R  A, Schwartz RL, Sostman HD, et al. NEJM Catalyst. 2021;2.
This article summarizes the principles of high reliability organizations (HROs) and how one healthcare organization sought to become an HRO by emphasizing a culture of safety and the learning healthcare system. The authors discuss how the principles of high-reliability were successfully leveraged during the COVID-19 pandemic.
Seufert S, de Cruppé W, Assheuer M, et al. BMJ Open. 2021;11:e052973.
Patient reports of patient safety incidents are one method to detect safety hazards. This telephone survey of German citizens found that patients frequently report patient safety incidents back to their general practitioner or specialist and these incidents can lead to loss of trust in the physician.
Hinkley T‐L. J Nurs Scholarsh. 2022;54:258-268.
Clinicians can experience adverse psychological consequences after making a mistake. This survey of 1,167 nurses found that social capital (both alone and in combination with psychological capital) has a significant impact on the severity of these adverse psychological outcomes.
Walshe N, Ryng S, Drennan J, et al. Int J Nurs Stud. 2021;124:104086.
Situation awareness refers to the degree to which perception matches reality. This narrative review explored how situation awareness has been defined and studied in healthcare, with a particular focus on nursing. Three overarching themes were identified: (1) individual, team and systems perspectives of situation awareness; (2) situation awareness and patient safety, and (3) communication tools, technologies and education to support situation awareness. The authors note that future research should reflect nurse’s work and the constrictions imposed on situation awareness by the demands of busy impatient wards.
Shojania KG. Jt Comm J Qual Patient Saf. 2021;47:755-758.
Incident reporting has long been advocated as a central strategy supporting error reduction, transparency and safety culture, but its implementation and use faces challenges. This commentary challenges the viability of the concept in healthcare, examines barriers to its success, and discusses a technology- based approach to reduce clinician reporting burden.

Jacksonville University.

Inspired by the research and leadership of Dr. Robert Wears, this award annually recognizes individuals, teams or organizations that examine the applications of safety science concepts to improve medicine. The deadline for submitting a 2022 award nomination is January 3, 2022.

Hostetter M, Klein S. New York, NY: Commonwealth Fund;  October 18, 2021

Structural racism affects the safety and equity of care delivery. This report summarizes organizational efforts to reduce the impact of systemic racism on patient care, hiring practices, and policy implementation to ensure transparent, equitable and patient-centered care is reliably available to all.

Joseph A. Stat News. November 22, 2021

The opioid epidemic has put regulatory and professional pressures on the tapering of pain medications that have had unintended consequences for patients resulting in harm. This news story discusses how one family used legal means to address systemic gaps and clinical missteps that resulted in patient suicide due to lack of appropriate pain control.

Bergl PA, Nanchal RS, eds. Crit Care Clin. 2022;38(1):1-158.

Critical care diagnosis is complicated by factors such as stress, patient acuity and uncertainty. This special issue summarizes individual and process challenges to the safety of diagnosis in critical care. Articles included examine educational approaches, teamwork and rethinking care processes as improvement strategies.
Tumelty M-E. J Patient Saf. 2021;17:e1488-e1493.
There has been some controversy around the term ‘second victim.’ Based on qualitative interviews with representatives of medical training organizations and legal professionals in Ireland, this study found that the use of term ‘second victim’ can be seen as insensitive to the patient and can erode the professional identity of the healthcare provider.
Joint Commission.
The Speak Up campaign provides sets of materials to enable patients and families to engage in making their health care experiences as safe as possible. Topics covered include safe surgery, pain management, medication safety, and most recently, discrimination reduction. Each topical package includes infographics, videos, instruction guides, and a podcast. 

A 77-year-old man was diagnosed with a rectal mass. After discussing goals of care with an oncologist, he declined surgical intervention and underwent targeted radiotherapy before being lost to follow up. The patient subsequently presented to Emergency Department after a fall at home and was found to have new metastatic lesions in both lungs and numerous enhancing lesions in the brain. Further discussions of the goals of care revealed that the patient desired to focus on comfort and on maintaining independence for as long as possible. The inpatient hospice team discussed the potential role

A 32-year-old pregnant woman presented with prelabor rupture of membranes at 37 weeks’ gestation. During labor, the fetal heart rate dropped suddenly and the obstetric provider diagnosed umbilical cord prolapse and called for an emergency cesarean delivery. Uterine atony was noted after delivery of the placenta, which quickly responded to oxytocin bolus and uterine massage.

De Cassai A, Negro S, Geraldini F, et al. PLoS One. 2021;16:e0257508.
Inattentional blindness occurs when individuals miss an unexpected event due to competing attentional tasks.  This study asked anesthesiologists to review the anesthetic management of five simulated cases, one of which included the image of a gorilla in the radiograph, to evaluate inattentional blindness. Only 4.9% of social media respondents reported an abnormality, suggesting that inattentional blindness may be common; the authors suggest several strategies to reduce this error.
McHale S, Marufu TC, Manning JC, et al. Nurs Crit Care. 2021;Epub Oct 20.
Failure to identify and prevent clinical deterioration can reflect the quality and effectiveness of care. This study used routinely collected emergency event data to identify failure to rescue events at one tertiary children’s hospital. Over a nine-year period, 520 emergency events were identified; 25% were cardiac arrest events and 60% occurred among patients who had been admitted for more than 48 hours. Over the nine-year period, failure to rescue events decreased from 23.6% to 2.5%.
Walton E, Charles M, Morrish W, et al. J Patient Saf. 2022;18:e620-e625.
Dialysis is a common procedure that carries risks if not performed correctly. This study analyzed dialysis-related bleeding events reported to the Veterans Health Administration Patient Safety Authority over an 18-year period. The analysis identified four areas of focus to reduce bleeding events – (1) the physical location and equipment used, (2) staff commitment to standardization and attention to detail (to reduce unwitnessed bleeding events), (3) mental status of the patient, and (4) the method for hemodialysis delivery.