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Galatzan BJ, Carrington JM. Res Nurs Health. 2021;44(5):833-843.
During handoffs, nurses are exposed to a variety of interruptions and distractions which may lead to cognitive overload. Using natural language processing, researchers analyzed ten audio-recorded change of shift handoffs to estimate the cognitive load experienced by nurses. Nurses’ use of concise language has the potential to decrease cognitive overload and improve patient outcomes.
Sharma AE, Huang B, Del Rosario JB, et al. BMJ Open Qual. 2021;10(3):e001421.
Patients and caregivers play an essential role in safe ambulatory care. This mixed-methods analysis of ambulatory safety reports identified three themes related to patient and caregivers factors contributing to events – (1) clinical advice conflicting with patient priorities, (2) breakdowns in communication and patient education contributing to medication adverse events, and (3) the fact that patients with disabilities are vulnerable to due to the external environment.  
Sotto KT, Burian BK, Brindle ME. J Am Coll Surg. 2021;233(6):794-809.e8.
The World Health Organization (WHO) Surgical Safety Checklist has been implemented in healthcare systems around the world. This systematic review and thematic analysis concluded that the surgical safety checklist positively impacts clinical outcomes (surgical outcomes and mortality), process measures, team dynamics, and communication, as well as safety culture. The authors note that the checklist was negatively associated with efficiency and workload; included studies often noted that checklist users felt the checklist slowed down processes within the operating room
Debriefing is an important strategy for learning about and making improvements in individual, team, and system performance. It is one of the central learning tools in simulation training and is also recommended after significant clinical events.
Burden AR, Potestio C, Pukenas E. Adv Anesth. 2021;39:133-148.
Handoffs occur several times during a perioperative encounter, increasing the risk of communication errors. Structured handoffs, such as situation-background-assessment-recommendation (SBAR) and checklists, have been shown to improve communication between providers during anesthesia care. The authors discuss how these tools and other processes can improve shared understanding of effective handoffs.
Krishnan S, Wheeler KK, Pimentel MP, et al. J Healthc Risk Manag. 2021;Epub Oct 28.
Incident reporting systems are used to detect patient safety concerns and determine potential causes and opportunities for improvements. In the perioperative setting of one hospital, insufficient handoffs were the most common event type in the “coordination of care” category. Use of structured handoffs is recommended to improve communication and patient safety.
Manias E, Street M, Lowe G, et al. BMC Health Serv Res. 2021;21(1):1025.
This study explored associations between person-related (e.g., individual responsible for medication error), environment-related (e.g., transitions of care), and communication-related (e.g., misreading of medication order) medication errors in two Australian hospitals. The authors recommend that improved communication regarding medications with patients and families could reduce medication errors associated with possible or probable harm.
Chauhan A, Walpola RL. Int J Qual Health Care. 2021;33(4):mzab145.
Health care decision making and delivery are vulnerable to unconscious bias. This commentary discusses strategies in place to address unconscious bias as it affects medication safety. The authors suggest a focus on engaging ethnic minority consumers as partners to design improvement programs to enhance medication delivery.
Hyvämäki P, Kääriäinen M, Tuomikoski A-M, et al. J Patient Saf. 2021;Epub Aug 23.
Previous studies have demonstrated health information exchanges (HIE) can improve the quality and safety of care by improving diagnostic concordance and reducing medication errors. This review synthesizes physicians’ and nurses’ perspectives on patient safety related to use of HIE in interorganizational care transitions. Several advantages of and challenges with HIE are detailed.
Meyer AND, Giardina TD, Khawaja L, et al. Patient Educ Couns. 2021;104(11):2606-2615.
Diagnostic uncertainty can lead to misdiagnosis and delayed treatment. This article provides an overview of the literature on diagnosis-related uncertainty, where uncertainty occurs in the diagnostic process and outlines recommendations for managing diagnostic uncertainty.
Silverglow A, Johansson L, Lidén E, et al. Scand J Caring Sci. 2021;Epub Aug 24.
Home care settings harbor unique patient safety challenges. This qualitative study identified three themes regarding care providers’ perceptions of providing safe care for frail older adults living at home – the role of the encounter and interaction, the responsibility of the caregiver, and the threat of insufficient organizational resources.
Braverman A. Nurs Manage. 2021;52(9):30-34.
In high-consequence environments, differences of opinion can undermine teamwork and result in operational failure. This article discusses the application of crew resource management (CRM) to the clinical environment. The author outlines steps to translate the aviation CRM experience into the health care domain to improve communication and resolve conflicts in stressful situations.
American Society for Healthcare Risk Management. Louisville, KY, April 4-9, 2022.
This onsite program will cover key patient safety concepts and how to apply them to improve safety. To help prepare attendees for designing and sustaining safety initiatives at their organizations, preconference activities will discuss safety culture, human factors, communication, and leadership development.
O’Dowd E, Lydon S, Lambe KA, et al. Fam Pract. 2021;Epub Sep 20.
Patient complaints can identify opportunities for patient safety improvement. This study explored whether an existing tool for measuring the severity of patient complaints – the Healthcare Complaints Analysis Tool – can effectively analyze complaints specific to general practice. Key issues identified by the study involved relationships (e.g., communication, patient rights) as well as clinical and management issues.
Bell SK, Bourgeois FC, DesRoches CM, et al. BMJ Qual Saf. 2021;Epub Oct 16.
Engaging patients and families in their own care can improve outcomes, safety, and satisfaction. This study brought patients, families, clinicians and experts together to identify patient-reported diagnostic process-related breakdowns. The group identified 7 categories, 40 subcategories, 19 contributing factors and 11 patient-reported impacts. Breakdowns were identified in each step of the diagnostic process.

Deprescribing is an intervention used to reduce the risk of adverse drug events (ADEs) that can result from polypharmacy. It is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use.

Brühwiler LD, Niederhauser A, Fischer S, et al. BMJ Open. 2021;11(10):e054364.
Polypharmacy and potentially inappropriate medications continue to pose health risks in older adults. Using a Delphi approach, experts identified 85 minimal requirements for safe medication prescribing in nursing homes. The five key topics recommend structured, regular review and monitoring, interprofessional collaboration, and involving the resident.
Klimmeck S, Sexton BJ, Schwendimann R. Jt Comm J Qual Patient Saf. 2021;47(12):783-792.
Safety WalkRounds involve health care leadership or managers visiting frontline staff and engaging in discussions about safety concerns. One university hospital in Switzerland combined WalkRounds with structured in-person observations which helped identify safe care practices and deficits in patient safety. However, there were no significant changes in safety and teamwork climate nine-months after implementation.  
Morse KE, Chadwick WA, Paul W, et al. Pediatr Qual Saf. 2021;6(4):e436.
The goal of medication reconciliation is to identify medication inconsistencies at hospital discharge. This study identified six common medication reconciliation errors at discharge – duplication, missing route, missing dose, missing frequency, unlisted medication, and “see instructions” errors. The authors evaluated the prevalence of these errors at two pediatric hospitals and found that duplication and “see instructions” errors were most common.