The PSNet Collection

Presenting complaint: use of language that disempowers patients.

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Cox C, Fritz Z. BMJ. 2022;377:e066720.

As more patients are gaining access to their electronic health records, including clinician notes, the language clinicians use can shape how patients feel about their health and healthcare provider. This commentary describes how some words and phrases routinely used in provider notes, such as “deny” or “non-compliant”, may inadvertently build distrust with the patient. The authors recommend medical students and providers reconsider their language to establish more trusting relationships with their patients.

Establishing psychological safety in clinical supervision: multi-professional perspectives.

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Lee EH, Pitts S, Pignataro S, et al. Clin Teach. 2022;19:71-78.

The inherent power imbalance between supervisors and new clinicians may inhibit new clinicians from asking questions or reporting mistakes. This lack of psychological safety can result in patient harm and restrict learning. This article provides strategies for healthcare educators and leaders to model and guide a safer organization. Three phases of the supervisor-learner relationship, along with suggested prompts, are provided.

Anti-black racism as a chronic condition.

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Sederstrom N, Lasege T. Hastings Cent Rep. 2022;52:s24-s29.

Racial bias and systemic racism in healthcare are increasingly seen as critical patient safety issues. This commentary discusses the relationship between medical ethics and racism in healthcare institutions, using examples such as racial biases in clinical tools and algorithms, the effect of racial bias on diagnosis and diagnostic error, and how excess disease burden can be viewed as proxy for racism.

Clinician distress and inappropriate antibiotic prescribing for acute respiratory tract infections: a retrospective cohort study.

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Brady KJS, Barlam TF, Trockel MT, et al. Jt Comm J Qual Patient Saf. 2022;48:287-297.

Inappropriate prescribing of antibiotics to treat viral illnesses is an ongoing patient safety threat. This study examined the association between clinician depression, anxiety, and burnout and inappropriate prescribing of antibiotics for acute respiratory tract infections (RTIs) in outpatient care. Depression and anxiety, but not burnout, were associated with increased adjusted odds of inappropriate prescribing for RTIs.

Fast tracking in cardiac surgery: is it safe?

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MacLeod JB, D’Souza K, Aguiar C, et al. J Cardiothorac Surg. 2022;17:69.

Post-operative complications can lead to increased length of hospital stay, cost, and resource utilization. This retrospective study compared “fast track” patients (patients extubated and transferred from ICU to a step-down unit the same day as their procedure) and patients who were not fast tracked. Results showed fast track pathways led to a reduction in ICU and overall hospital length of stay and similar post-operative outcomes.

Responding to safe care: healthcare staff experiences caring for a child with intellectual disability in hospital. Implications for practice and training.

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Ong N, Long JC, Weise J, et al. J Appl Res Intellect Disabil. 2022;35:675-690.

Children with intellectual disabilities can be at higher risk for patient safety events and poor-quality care. This systematic review and thematic analysis identified several themes (e.g., distress, communication, training, and education) underscoring healthcare staff experiences in providing care for pediatric patients with intellectual disabilities. The review found that healthcare staff feel they lack necessary skills to provide care for children with intellectual disabilities and have difficulties communicating effectively with both patients and their parents.

The Color of Care.

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Chicago, IL: Harpo Productions, Smithsonian Channel: May 2022.

The COVID-19 pandemic revealed the impact of racial disparities and inequities on patient safety for patients of color. This film shares stories of families whose care was unsafe. The cases discussed highlight how missed and dismissed COVID symptoms and inattention to patient and family concerns due to bias reduces patient safety.

Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error.

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Institute for Safe Medication Practices and the Just Culture Company. May 6, 2022.

Organizational factors can contribute to the occurrence of patient safety events and how health systems respond to such events. This webinar highlighted lessons learned in the aftermath of a fatal medication error, and strategies to improve patient safety at the organizational level through system design and accountability.

Identifying patients whose symptoms are underrecognized during treatment with breast radiotherapy.

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Jagsi R, Griffith KA, Vicini F, et al for the Michigan Radiation Oncology Quality Consortium. JAMA Oncol. Epub 2022 Apr 21.

Concordance of patient-reported symptoms and provider-documented symptoms is necessary for appropriate patient care and has clinical implications for research. This study compared patient-reported symptoms (pain, pruritus, edema, and fatigue) following radiotherapy for breast cancer with provider assessments. Underrecognition of at least one symptom occurred in more than 50% of patients. Underrecognition was more common in Black patients and those seen by male physicians. The authors suggest that interventions to improve communication between providers and patients may not only improve outcomes but also reduce racial disparities.

The patient's "story": an examination of patient-reported safety incidents in general practice.

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Madden C, Lydon S, Murphy AW, et al. Fam Pract. 2022;Epub Apr 20.

Patient complaints and patient-reported incidents can help identify safety issues. This study compared clinician perceptions and patients’ accounts regarding patient safety incidents and identified a significant difference in perceptions about incident severity. Patients’ accounts of incidents commonly described deficiencies related to communication, staff performance, compassion, and respect.

Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS.

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London UK: Patient Safety Learning: 2022.

Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financially. This report examines large system failures in the UK National Health Service to suggest actions that support learning and improvement. The publication highlights how public investigations, government reports, legal actions, and patient complaints can provide information to support the systems approach required to arrive at safe care.

ISMP Guidelines for Sterile Compounding and the Safe Use of Sterile Compounding Technology.

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Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.

This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety. In addition, it covers safe practices when technologies are not available.

AORN Position Statement on Patient Safety.

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AORN J. 2022;115:454-457.

This position statement outlines recommendations from the Association of periOperative Registered Nurses on core components of safe perioperative nursing and its role in strengthening patient safety. Elements discussed include error reduction, leadership engagement, and safe working environment..

Patient Safety Authority Annual Reports.

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Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.

This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.

The Media’s Role in Patient Safety

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April 27, 2022

This piece discusses the role that media plays in affecting patient safety.

Intraosseous Line Extravasation in a Pediatric Trauma Patient

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April 27, 2022

An 18-month-old girl presented to the Emergency Department (ED) after being attacked by a dog and sustaining multiple penetrating injuries to her head and neck. After multiple unsuccessful attempts to establish intravenous access, an intraosseous (IO) line was placed in the patient’s proximal left tibia to facilitate administration of fluids, blood products, vasopressors, and antibiotics. In the operating room, peripheral intravenous (IV) access was eventually obtained after which intraoperative use of the IO line was restricted to a low-rate fluid infusion.

Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room

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April 27, 2022

This WebM&M describes an adverse event due to mislabeling or “syringe swap” in a preoperative patient. The commentary outlines several recommendations and safeguards to ensure that medications administration is safe.

Conversations on diagnostic uncertainty and its management among pediatric acute care physicians.

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Patel SJ, Ipsaro A, Brady PW. Hosp Pediatr. 2022;Epub Feb 28.

Diagnostic uncertainty can arise in complex clinical scenarios. This qualitative study explored how physicians in pediatric emergency and inpatient settings mitigate diagnostic uncertainty. Participants discussed common mitigation strategies, such as employing a “diagnostic pause.” The authors also noted outstanding gaps regarding communicating diagnostic uncertainty to families.

Progress achieved: The 2021 John M. Eisenberg Patient Safety and Quality Award Winners.

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Oakbrook Terrace, IL: Joint Commission: April 19, 2022.

The Eisenberg Award recognizes individual and organizational accomplishment toward patient safety and quality improvement. The 2021 honorees are Hardeep Singh, MD, MPH, Prime Healthcare Services, Ontario, California, Kaiser Permanente Northern California, Oakland, California, and Mark R. Chassin, MD, FACP, MPP, MPH. The awards will be presented virtually during the National Quality Forum's annual meeting in July.

A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic

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April 27, 2022

In the early days of the COVID-19 pandemic, New York Presbyterian Weill Cornell Medical Center and Lower Manhattan Hospital faced multiple challenges.

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