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De Angulo NR, Penwill N, Pathak PR, et al. Hosp Pediatr. 2021;Epub Dec 24.
This study explored administrator, physician, nurse, and caregiver perceptions of safety in pediatric inpatient care during the first months of the COVID-19 pandemic. Participants reported changes in workflows, discharge and transfer process, patient and family engagement, and hospital operations.
Duffy B, Miller J, Vitous CA, et al. J Patient Saf. 2021;17:e1765-e1773.
Healthcare providers are increasingly disclosing their errors to patients. This review summarizes available guidance for how and when to report other providers’ errors, particularly those outside their own facility or system. Guidelines tended to be ambiguous and restricted to incompetence.
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.
Winning AM, Merandi J, Rausch JR, et al. J Patient Saf. 2021;17:531-540.
Healthcare professionals involved in a medical error often experience psychological distress. This article describes the validation of a revised version of the Second Victim Experience and Support Tool (SVEST-R), which was expanded to include measures of resilience and desired forms of support.

Dean J, Subbe C, eds. Future Healthc J. 2021;8(3):e559-e618.

Full realization of the patient voice as a resource for safety is challenging. This special section provides global perspectives examining cultural, organizational, and system-focused opportunities to fully use patient knowledge in improvement initiatives.
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.
Draus C, Mianecki TB, Musgrove H, et al. J Nurs Care Qual. 2022;37:110-116.
“Second victims” are healthcare providers who experience negative feelings in their personal or professional lives after being involved in unanticipated adverse patient events. One hundred and fifty-nine nurses at one American hospital reported being a second victim and experiencing psychological and/or physical distress following the incident.
Yansane A, Tokede O, Walji MF, et al. J Patient Saf. 2021;17:e1050-e1056.
Clinician burnout is a known threat to patient safety. This survey of a national sample of dentists found that approximately 1 in 10 respondents reported high levels of burnout and 50% of respondents reported a perceived dental error in the last 6 months. Efforts to minimize burnout among dentists may help improve patient safety.

Glicksman E. Washington Post. December 11, 2021.

A successful patient/physician relationship enables care that is specific for the individual, their unique concerns, and distinct lifestyles. This article discusses patient choice in physicians as a strategy to reduce the impact of implicit ethnic bias, while arguing that fundamental change will occur only by reducing racism through system change.
Bryant BE, Jordan A, Clark US. JAMA Psych. 2022;79:93-94.
Research and medical practice are negatively affected by systemic and implicit bias. This commentary discusses this phenomenon in the mental health sector and suggests a role for researchers to reduce the inappropriate use of race in psychiatric practice while limiting its detrimental impact on care nationwide.
Thomas AD, Pandit C, Krevat SA. J Patient Saf. 2021;17:e1605-e1608.
Building on prior research, this study identified racial differences in voluntarily reported near-miss events. Compared to white patients, black patients had fewer reported events but were more likely to experience near-miss events related to laboratory/specimen handling, blood bank, and safety/security.
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.
Hannawa AF, Wu AW, Kolyada A, et al. Patient Educ Couns. 2022;105:1561-1570.
In this qualitative study, researchers explore physician, nurse, and patient perspectives about what features constitute “good” and “poor” care episodes. Participants highlighted the importance of quickly identifying and responding to errors and failures as one key component of good quality care.
Blease CR, Kharko A, Hägglund M, et al. PLoS ONE. 2021;16:e0258056.
Allowing patients to access their own ambulatory clinical health record has benefits such as identification of errors and increased trust. This study focused on risks and benefits of patient access to mental health care records. Experts suggested the benefits would be similar to those seen in primary care, such as increased patient engagement, with the potential additional benefit of reduced stigmatization.
Ellis LA, Tran Y, Pomare C, et al. BMC Health Serv Res. 2021;21:1256.
This study investigated the relationship between hospital staff perceived sociotemporal structures, safety attitudes, and work-related well-being. The researchers identified that hospital “pace” plays a central role in understanding that relationship, and a focus on “pace” can significantly improve staff well-being and safety attitudes.