Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
161 - 180 of 17075

Graber ML, Schrandt S. Evanston, IL:  Society to Improve Diagnosis in Medicine;  September 8, 2021. 

This report summarizes the results of a project that examined how the literature and various stakeholders consider challenges and opportunities for improving diagnosis during telemedicine interactions. Both areas of concern and potential were highlighted to engage researchers, educators, and clinicians in the implementation and use of telediagnosis that is safe and of high-value for patients and families.
NIOSH [2015]. NIOSH training for nurses on shift work and long work hours. By Caruso CC, Geiger-Brown J, Takahashi M, Trinkoff A, Nakata A. Cincinnati, OH: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2015-115 (Revised 10/2021)
Nurse fatigue has been associated with diminished decision-making skills that can contribute to patient harm. This online training program for clinicians and administrators will explore hazards related to nurse fatigue and provide strategies to address behaviors and systems that increase these risks.
US Food and Drug Administration. October 7, 2021.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this updated announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.
Ceschi A, Noseda R, Pironi M, et al. JAMA Netw Open. 2021;4(9):e2124672.
Medication reconciliation at hospital discharge can result in reduction of adverse events when the patient returns to the community. This study measured the effect of medication reconciliation performed at admission to hospital on subsequent health care outcomes. For patients ages 85 years and older, taking more than 10 medications at hospital admission, or both, medication reconciliation at admission did not have an impact on 30-day readmission to hospital.
Holmgren AJ, Bates DW. JAMA Netw Open. 2021;4(9):e2125173.
Hospitals participating in the voluntary Leapfrog program must publicly report data on several quality measures. Hospitals that participated in the Computerized Provider Order Entry (CPOE) Evaluation Tool, which measures medication safety, had a mean score of 59.3% at baseline. Hospitals that received negative feedback showed greater improvement than hospitals that received positive feedback, demonstrating the utility of public reporting in improving quality.
Kwok CS, Bennett S, Azam Z, et al. Crit Pathw Cardiol. 2021;20(3):155-162.
Misdiagnosis of cardiovascular conditions can lead to serious patient harm. This systematic review found that misdiagnosis of acute myocardial infarction (AMI) occurs in approximately 1-2% of cases, and AMI is commonly diagnosed as other heart conditions, musculoskeletal pain, or gastrointestinal disease. The authors suggest that there are opportunities to reduce cases of missed AMI with better education about atypical symptoms and improved training of electrocardiogram interpretation.

Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.

Maternal safety is threatened by systemic biases, care complexities, and diagnostic issues. This issue brief explores the role of diagnostic error in maternal morbidity and mortality, the preventability of common problems such as maternal hemorrhage, and the importance of multidisciplinary efforts to realize improvement. The brief focuses on events occurring during childbirth and up to a week postpartum.
Bosson N, Kaji AH, Gausche-Hill M. Prehosp Emerg Care. 2021;Epub Jul 14.
Pediatric medication administration in prehospital care is challenging due to the need to obtain an accurate weight and calculate dosing. The Los Angeles County emergency medical services implemented a Medical Control Guideline (MCG) to eliminate the need to calculate the dose of a commonly administered medication. Following implementation of the MCG, dosing errors decreased from 18.5% to 14.1% in pediatric prehospital care.
Bouwman R, Bomhoff M, Robben PB, et al. J Patient Saf. 2021;17(7):473-482.
When appropriately responded to and addressed, patient complaints may help prevent adverse events. In this study of patient complaints filed with the Dutch Healthcare Inspectorate, researchers investigated how patients expected their complaint would impact healthcare quality, whether patients and regulators had similar expectations, and if expectations are different whether the complaints are clinical or nonclinical in nature. Results show a mismatch between expectations of patients and regulators.
Burke HB, King HB. BMJ Open. 2021;11(9):e040779.
This study of US primary care physicians tested their patient safety and quality knowledge. Five topic areas were assessed: 1) patient management, 2) radiation risk, 3) general safety and quality, 4) structure, process, and outcome, and, 5) quality and safety definitions. The average score was 48% correct, indicating additional education in patient safety and quality for practicing primary care physicians is needed.
Fernández‐Aguilar C, Martín‐Martín JJ, Minué Lorenzo S, et al. J Eval Clin Pract. 2021;Epub Aug 11.
Heuristics, or the use of mental shortcuts based on experience or trial and error that allow clinicians to quickly assess or diagnose a problem, can sometimes result in misdiagnosis. Three types of heuristics are explored in this study of primary care diagnostic error: representativeness, availability, and overconfidence. While a diagnostic error was identified in nearly 10% of cases, there was no significant correlation between the use of heuristics and diagnostic error.
Gluschkoff K, Kaihlanen A, Palojoki S, et al. Safety Sci. 2021;144:105450.
Organizational culture can influence whether or not clinicians report patient safety incidents. Nurses were surveyed about their experiences with non-reporting of health information technology (HIT)-related safety incidents. Approximately half of respondents indicated that they did not file a report when encountering an HIT-related incident. The authors suggest strengthening organizational culture may increase reporting.
Hu X, Casey T. J Adv Nurs. 2021;77(9):3733-3744.
Speaking up about concerns is essential to improving safety, but prior research has found that many healthcare workers do not feel comfortable speaking up. In this study, staff members from a disability healthcare organization in Australia responded to a questionnaire regarding organizational identification and culture of safety. Findings highlight the importance of organizational identification and management commitment to safety and psychological safety in promoting speaking up behaviors.

King AE, Gerolamo AM, Hass RW, et al. J Allied Health. 2021;50(3):175-181.

Teamwork is essential for effective care coordination and patient safety. This study found that this specific educational intervention (TeamSAFE, which consisted of an online learning module and in-person interprofessional teamwork simulations) for medical, nursing, and allied health students improved knowledge of teamwork skills, increased understanding of the roles and responsibilities of different health professions, and the importance of patient safety.  
Kukielka E. Patient Saf. 2021;3(3):18-27.
Trauma patients, who often suffer multiple, severe injuries and who may arrive to the Emergency Department (ED) unconscious, are vulnerable to adverse events. Using data reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers in this study evaluated the safety challenges of caring for patients presenting to the ED after a motor vehicle collision. Common challenges included issues with monitoring, treatment, evaluation, and/or documentation, patient falls, medication errors, and problems with transfers.
Liu LQ, Mehigan S. AORN J. 2021;114(2):159-170.
Surgical safety checklists (SSC) have been shown to improve outcomes, but effective implementation remains a challenge. This systematic review evaluated the effectiveness of interventions to increase compliance with the World Health Organization’s SSC for adult surgery. Interventions generally fell into one of four categories: modifying the method of SSC delivery, integrating or tailoring the tool for local context, promoting awareness and engagement, and managing organizational policy. Study findings suggest that all approaches resulted in some improvement in compliance.
Ranum D, Beverly A, Shapiro FE, et al. J Patient Saf. 2021;17(7):513-521.
This analysis of medical malpractice claims identified four leading causes of anesthesia-related claims involving ambulatory surgery centers – dental injuries, pain, nerve damage, and death. The authors discuss the role of preoperative risk assessment, use of routine dental and airway assessment, adequate treatment of perioperative pain, and improving communication between patients and providers.
Stovall M, Hansen L. Worldviews Evid Based Nurs. 2021;18(5):264-272.
Clinicians who are involved in a patient safety incident often experience significant emotional consequences. This study found that nurses involved in an patient safety incident resulting in patient death were more likely to change jobs, consider leaving the profession, and have suicidal ideation, compared to nurses involved in incidents that did not result in patient harm.
Weenink J-W, Wallenburg I, Leistikow I, et al. BMJ Qual Saf. 2021;30(10):804-811.
This qualitative study explored the impact of published inspection frameworks on quality and safety in nursing home care, dental care, and hospital care. Respondents noted the importance of the inspection framework design, the role of existing institutional frameworks, and how the frameworks can influence quality improvement across various organizational levels.
Waddell AE, Gratzer D. Can J Psychiatry. 2021:070674372110365.
Safety gaps in mental health care offers a limited view if focused primarily on patient suicide. This commentary calls for Canadian psychiatric professionals to examine the safety of their patients from a system perspective to develop a research and practice improvement strategy.