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Hegarty J, Flaherty SJ, Saab MM, et al. J Patient Saf. 2021;17:e1247-e1254.
Defining and measuring patient safety is an ongoing challenge. This systematic review explored international approaches to defining serious reportable patient safety incidents. Findings indicate wide variation in terminology and reporting systems among countries which may contribute to missed opportunities for learning. Serious reportable patient safety events were commonly defined as being largely preventable; having the potential for significant learning; causing serious harm or having the potential to cause serious harm; measurable and feasible to report, and; running the risk of recurrence.
Kuznetsova M, Frits ML, Dulgarian S, et al. JAMIA Open. 2021;4:ooab096.
Dashboards can be used to synthesize data and visualize patient safety indicators and metrics to facilitate decision-making. The authors reviewed design features of patient safety dashboards from 10 hospitals and discuss the variation in the use of performance indicators, style, and timeframe for displayed metrics. The authors suggest that future research explore how specific design elements contribute to usability, and which approaches are associated with improved outcomes.
Malevanchik L, Wheeler M, Gagliardi K, et al. Jt Comm J Qual Patient Saf. 2021;47:775-782.
Communication in healthcare is essential but can be complicated, particularly when there are language barriers between providers and patients. This study evaluated a hospital-wide care transitions program, with a goal of universal contact with discharged patients to identify and address care transition problems. Researchers found that the program reached most patients regardless of English proficiency, but that patients with limited English proficiency experienced more post-discharge issues, such as difficulty understanding discharge instructions, medication concerns and follow-up questions, and new or worsening symptoms.
Nassery N, Horberg MA, Rubenstein KB, et al. Diagnosis (Berl). 2021;8:469-478.
Building on prior research on missed myocardial infarction, this study used the SPADE approach to identify delays in sepsis diagnosis. Using claims data, researchers used a ‘look back’ analysis to identify treat-and-release emergency department (ED) visits in the month prior to sepsis hospitalizations and identify common diagnoses linked to downstream sepsis hospitalizations.
Tzeng H-M, Raji MA, Chou L-N, et al. J Nurs Care Qual. 2021;37:6-13.
Potentially inappropriate medications (PIMs) for older adults carry a high risk of adverse drug events. Using a sample of Medicare beneficiaries from 2015 to 2018, researchers assessed the impact of state scope of practice regulations for nurse practitioners (NPs) on PIM prescribing patterns compared to primary care physicians. Findings indicate that the PIM prescribing rate is lower in states with full NP practice and lower among NPs than among physicians.
Berwick DM. JAMA. 2021;326:2127-2128.
Efforts to improve diagnosis recognize the value in patient-centered care. This commentary outlines how a diagnostician can enfold patient centeredness into their practice, which includes the seeking of knowledge and moderation of actions taken to arrive at a diagnosis. This piece is part of a series on diagnostic excellence.

EQT Plaza, 625 Liberty Ave, Ste. 2500, Pittsburgh, PA 15222.

Centralized reporting and analysis of adverse events in health care is a safety improvement model from the aviation industry that has yet to be enabled in health care. This organization shares information to support the establishment of a national body charged with the  collection and monitoring of adverse event data to inform research and recommendations for medical error reduction.

ECRI and Institute for Safe Medication Practices. January 2022 through May 2022.

Collaboratives provide teams with active learning and improvement opportunities based on the experiences of others working toward a collective goal. This collaborative will target safety during surgical procedures. The discussions protected under the sponsors’ Patient Safety Organization status will explore improvement topics such as medication errors and surgical site infections.

Ackerman RS, Patel SY, Costache M, et al. Anesthesiology News. November 21, 2021.

Blame is known to limit discussions of near-misses and failures, which negatively impacts learning and incident reduction. This article describes work to examine blameful context present in anesthesiology incident documentation, reducing its viability as a successful investigation record. Length of text was identified as an enabler of blameful orientation, and limitations as to word count were one strategy to minimize the use of punitive language.

Rockville, MD: Agency for Healthcare Research and Quality. January 12, 2022.

An organization’s understanding of its culture is foundational to patient safety. This webinar introduced the AHRQ Surveys on Patient Safety Culture™ (SOPS®) program. The session covered the types of surveys available and review resources available to best use the data to facilitate conversations and comparisons to inform improvement efforts. 

Society to Improve Diagnosis in Medicine.

The impact of diagnostic error is increasingly clarified as research defines primary areas of concern. This grant program will provide 20 seed grants to multidisciplinary teams that include patients. The work will devise and test interventions to improve the diagnostic process and includes areas of special interest exploring diagnosis in the older adult population and on cross-discipline teams. The 2022 application process closes March 25, 2022.
Ang D, Nieto K, Sutherland M, et al. Am Surg. 2022;88:587-596.
Patient safety indicators (PSI) are measures that focus on quality of care and potentially preventable adverse events. This study estimated odds of preventable mortality of older adults with traumatic injuries and identified the PSIs that are associated with the highest level of preventable mortality.  Strategies to reduce preventable mortality in older adults are presented (e.g. utilization of national guidelines, minimization of central venous catheter use, addressing polypharmacy).
Jessurun JG, Hunfeld NGM, Van Rosmalen J, et al. Int J Qual Health Care. 2021;33:mzab142.
Reducing medication administration errors (MAEs) is an ongoing patient safety priority. This prospective study assessed the impact of automated unit dose dispensing with barcode-assisted medication administration on MAEs at one Dutch hospital. Implementation was associated with a lower probability of MAEs (particularly omission errors and wrong dose errors), but impact would likely be greater with increased compliance with barcode scanning. 
Theobald KA, Tutticci N, Ramsbotham J, et al. Nurse Educ Pract. 2021;57:103220.
Simulation training is often used to develop clinical and nontechnical skills as part of nursing education.  This systematic review found that repeated simulation exposures can lead to gains in clinical reasoning and critical thinking. Two emerging concepts – situation awareness and teamwork – can enhance clinical reasoning within simulation. With more nursing schools turning to simulation to replace clinical site placement, which is in short supply, understanding of simulation in training is critical.
Benning S, Wolfe R, Banes M, et al. J Pediatr Nurs. 2021;61:372-377.
Patient falls represent a significant cause of patient harm. While most research on falls focus on the in-patient setting, this study reviewed research evidence and findings from environmental assessments to provide recommendations for reducing risk of falls in the pediatric ambulatory care setting. Three categories of barriers and interventions were identified: equipment and furniture, environment, and people.
Davila H, Rosen AK, Stolzmann K, et al. J Am Coll Clin Pharm. 2022;5:15-25.
Deprescribing is a patient safety strategy to reduce the risk of adverse drug events, particularly for patients taking five or more medications. Physicians, nurse practitioners, physician assistants, and clinical pharmacists in Veterans Affairs primary care clinics were surveyed about their beliefs, attitudes, and experiences with deprescribing. While most providers reported having patients taking potentially inappropriate or unnecessary medications, they did not consistently recommend deprescribing to their patients.
Fan B, Pardo J, Yu-Moe CW, et al. Ann Surg Oncol. 2021;28:8109-8115.
While prior research has described malpractice cases related to breast cancer diagnosis and treatment, this study sought to identify errors specifically related to breast cancer surgical procedures. Plastic surgeons were the most commonly named provider type (64%), error in surgical treatment was the most common allegation (87%), and infection, cosmetic injury, emotional trauma, foreign body, and nosocomial infection were the top 5 injury descriptions.
Gadallah A, McGinnis B, Nguyen B, et al. Int J Clin Pharm. 2021;43:1404-1411.
This comparison study assessed the impact of virtual pharmacy technicians (vCPhT) obtaining best possible medication histories from patients admitted to the hospital from the emergency department.  The rates of unintentional discrepancies per medication and incomplete medication histories were significantly lower for vCPhT than other clinicians. Length of stay, readmissions, and emergency department visits were similar for both groups.
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.