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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%.
Flowerdew L, Tipping M. Emerg Med J. 2021;38(10):769-775.
This study sought to validate an emergency department (ED) safety questionnaire developed in the United States, and adapted for use in the UK. The survey was validated by 33 patient safety leads and used in a multi-center survey. Analysis highlighted risks and positive factors (e.g., positive safety culture) present in surveyed EDs.
Härkänen M, Haatainen K, Vehviläinen-Julkunen K, et al. Int J Environ Res Public Health. 2021;18(17):9206.
Building on previous research on the use of text mining related to medication administration error incidents, researchers in this study found that artificial intelligence can be used to accurately classify the free text of medication incident reports causing serious or moderate harm, to identify target risk management areas.
Townsend T, Cerdá M, Bohnert AS, et al. Health Aff (Millwood). 2021;40(11):1766-1775.
Misuse of prescription opioids represents a serious patient safety issue. Using commercial claims from 2014 - 2018, researchers examined the association between the 2016 CDC guidelines to reduce unsafe opioid prescribing and opioid dispensing for patients with four common chronic pain diagnoses. Findings indicate that the release of the 2016 guidelines was associated with reductions in the percentage of patients receiving opioids, average dose prescribed, percentage receiving high-dose prescriptions, number of days supplied, and the percentage of patients receiving concurrent opioid/benzodiazepine prescriptions. The authors observe that questions remain about how clinicians are tailoring opioid reductions using a patient-centered approach.
Soncrant C, Mills PD, Pendley Louis RP, et al. J Patient Saf. 2021;17(8):e821-e828.
Using data from the Veterans Health Administration National Center for Patient Safety, this retrospective study found that suicide and opioid overdose are the most serious healthcare-related adverse events affecting homeless veterans. Identified root causes include issues related to risk assessment for suicidal or overdose behaviors as well as poor interdisciplinary communication and coordination of care.

ISMP Medication Safety Alert! Acute care edition. November 4, 2021;26(22); 1-4.

Delays in diagnosis and treatment during life-threatening emergencies such as strokes can result in irreversible patient harm. This article discusses a variety of factors contributing to errors in administering hypertonic sodium chloride in emergent situations. The piece shares recommendations touching on various elements of the medication delivery process to enhance safety.
Davidson JE, Doran N, Petty A, et al. Am J Crit Care. 2021;30(5):365-374.
The Joint Commission implemented medication management titration standards in 2017, with revisions in 2020. Researchers surveyed critical care nurses about their experiences with medication titration, use of clinical judgment when titrating, nurses’ scope and autonomy, and their moral distress. Of 781 respondents, 80% perceived the titration standards caused delays in patient care and 68% reported suboptimal care, both of which significantly and strongly predicted moral distress.
Molina RL, Benski A-C, Bobanski L, et al. Implement Sci Commun. 2021;2(1):76.
Checklists are widely used to improve patient safety, including reductions in catheter-related bloodstream infections and surgical morbidity and mortality. This study focuses on implementation of the 2015 World Health Organization Safe Childbirth Checklist (SCC) which aims to prevent maternal and neonatal morbidity and mortality. Twenty-nine participants from fifteen countries with SCC experience completed a survey and twelve were interviewed. Most reported adapting the SCC for their local setting and a wide variety of implementation strategies were used.
Skoogh A, Hall-Lord ML, Bååth C, et al. BMC Health Serv Res. 2021;21(1):1093.
Improving maternal safety is a priority patient safety issue. Using the Global Trigger Tool, researchers found that nearly three-quarters of adverse events in one labor ward in a Swedish hospital were preventable. Common events included lacerations and anesthesia-related events and often resulted in a prolonged hospital stay.
Orenstein EW, Kandaswamy S, Muthu N, et al. J Am Med Inform Assoc. 2021;28(12):2654-2660.
Alert fatigue is a known contributor to medical error. In this cross-sectional study, researchers found that custom alerts were responsible for the majority of alert burden at six pediatric health systems. This study also compared the use of different alert burden metrics to benchmark burden across and within institutions.

Understanding the ways in which human factors, such as non-technical skills, influence individual and team performance can ultimately improve patient safety, particularly in high-intensity settings such as operating rooms. The Observation of Non-technical Skills and Teamwork (ONSet) program, created by the Cambridge University Hospitals, uses observation and feedback from Human Factors Champions to evaluate the impact of human factors education in operating rooms.

Bjørn B, Anhøj J, Østergaard M, et al. J Patient Saf. 2021;17(1):e593-e598.
Trigger tools are used as signals to detect potential adverse events. Using the Institute for Healthcare Improvement Global Trigger Tool (GTT), one patient safety review team was unable to reproduce harm rates in a test-retest reliability study, suggesting the GTT may not be a reliable measure of harm over time. The team recommends additional test-retest studies in other hospitals.
Duzyj CM, Boyle C, Mahoney K, et al. Am J Perinatol. 2021;38(12):1281-1288.
Pregnancy and childbirth are recognized as high-risk activities for both the pregnant person and infant. This article describes the implementation of a postpartum hemorrhage patient safety bundle. Successes, challenges and recommendations for implementation are included.

National Confidential Inquiry into Suicide and Safety in Mental Health. Manchester, UK: University of Manchester; May 31, 2021

System failures require multifactorial assessment to install targeted improvements. This toolkit examines 10 areas of focus for organizations to assess the safety of mental health services in emergent and primary care settings to minimize patient suicide and self-harm. Areas of focus include post-discharge follow-up, admissions, and family engagement.
Sosa T, Sitterding M, Dewan M, et al. Pediatrics. 2021;148(4):e2020034603.
Situational awareness during critical incidents is a key attribute of effective teams. This article describes the development of a situational awareness model, which included involving families and the interdisciplinary team in huddles, a shared mental model checklist, and an electronic health record (EHR) situational awareness navigator. Use of this new model decreased emergency transfers to the ICU and improved process measures, such as improved risk recognition before medical response team activation.
The Joint Commission.
The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers. 
Volkar JK, Phrampus P, English D, et al. J Patient Saf. 2021;17(7):e689-e693.
The goal of peer review is to provide clinicians with the opportunity to learn from errors. A multidisciplinary panel at one academic medical center established a new approach for physician peer review which incorporated a protected electronic portal for communication and engagement and a Just Culture peer review algorithm to identify opportunities for system improvements. The new approach decreased the average time necessary for full case review and increased provider engagement.

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.