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A 52-year old women presented to the emergency department with a necrotizing soft tissue infection (necrotizing fasciitis) after undergoing cosmetic abdominoplasty (‘tummy tuck’) elsewhere. A lack of communication and disputes between the Emergency Medicine, Emergency General Surgery and Plastic Surgery teams about what service was responsible for the patient’s care led to delays in treatment. These delays allowed the infection to progress, ultimately requiring excision of a large area of skin and soft tissue.
Lemos C de S, Poveda V de B. J Perianesth Nurs. 2019;34:978-998.
This integrative review examined the factors contributing to perioperative adverse events resulting from anesthesia. Researchers found that both active errors, such as medication errors or inattention, and latent errors, such as communication failures, contributed to adverse events.
Pregnancy, childbirth, and the postpartum year present a complex set of patient safety challenges. Numerous maternal safety initiatives aim to prevent errors and harm, while enhancing readiness to address maternal complications.
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
A large and growing number of Americans require care in skilled nursing facilities, inpatient rehabilitation facilities, or long-term acute care hospitals, often after an acute hospitalization. Data indicates that more than 20% of patients in these settings experience an adverse event during their stay.
Deilkås ECT, Hofoss D, Husebo BS, et al. PLoS One. 2019;14:e0218244.
Researchers deployed the Norwegian version of the Safety Attitudes Questionnaire, a measure of safety culture, across long-term care facilities and found significant variations in scores. They conclude that safety culture measurement may be useful to align resources with needs to support patient safety.
Odell DD, Quinn CM, Matulewicz RS, et al. J Am Coll Surg. 2019;229:175-183.
Establishing a strong culture of safety is an important priority in the health care setting. Prior research examining the association between improved safety culture and patient outcomes has produced mixed results. Using a modified version of the Safety Attitudes Questionnaire (SAQ), researchers surveyed hospital leaders and frontline providers across 49 hospitals in the Illinois Surgical Quality Improvement Collaborative. Consistent with prior research, they found that hospital administrators had more positive perceptions of safety than frontline health care providers. They also found a significant association between improved safety culture as measured by the SAQ and reduced risk of postoperative morbidity and death. A past PSNet perspective discussed the impact of safety culture on safety.
An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service, with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath.
Ku BC, Chamberlain JM, Shaw KN. Pediatr Clin North Am. 2018;65:1269-1281.
Pediatric emergency care presents unique safety challenges for a vulnerable patient population. This review summarizes emergency department (ED) improvement work across the six domains of quality. The authors suggest that pediatric EDs adopt high reliability concepts to enhance collaboration and data-sharing to improve safety. They also call for increased focus on equity and patient-centeredness.
Pettis AM. AORN J. 2018;108:644-650.
Failure to adhere to evidenced-based practices can result in patient harm. This article explores how high reliability concepts can support the reliable use of best practices to prevent surgical site infections. The authors suggest a framework focused on team engagement, education, implementation, and evaluation to encourage the use of evidence-based practice on the front line.
This perspective examines the troubling decline in maternal health outcomes in the United States and summarizes recent national initiatives to improve safety in maternity care.
Monahan JJ. AORN J. 2018;108:548-552.
The good catch, or near miss, can provide a key learning experience in health care practice. This article discusses the importance of organizational culture in utilizing these experiences as improvement opportunities. The author reviews strategies for nurses to engage in skill development through case review of good catches.
Chicago, IL: Health Research & Educational Trust; 2018.
Proactive identification of conditions that degrade the diagnostic process can drive improvement. This toolkit provides resources to help organizations seeking to improve diagnosis. The publication includes case studies that illustrate implementation challenges and provides infrastructure enhancement suggestions for hospital teams as they design interventions to reduce diagnostic errors.
Jeffries M, Keers RN, Phipps DL, et al. PLoS One. 2018;13:e0205419.
Pharmacists enhance medication safety in hospitals and ambulatory settings. The authors interviewed pharmacists about their experience implementing a dashboard that allowed them to identify and provide feedback regarding hazardous medication prescribing in primary care. A WebM&M commentary describes other pharmacy-led efforts to make prescribing safer.
The British Diabetic Association; Diabetes UK.
Chronic disease management can add complexity to inpatient care regimens. Researchers worked with patients, system leaders, and clinicians to examine areas of risk for hospitalized patients with diabetes and determine solutions such as specialized teams, clinical leadership, and improved use of technology. A WebM&M commentary illustrated safety challenges associated with providing care for hospitalized patients with diabetes.

Azar FM, ed. Orthop Clin North Am. 2018;49(4):A1-A8,389-552.

Quality and value have intersecting influence on the safety of health care. Articles in this special issue explore key principles of safe orthopedic care for both adult and pediatric patients. Topics covered include leadership's role in implementing sustainable improvement, postsurgery patient education as a safety tactic, and the impact of surgical volume on safe, high-quality care.