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Bennion J, Mansell SK. Br J Hosp Med (Lond). 2021;82:1-8.
Many strategies have been developed to improve recognition of, and response, to clinically deteriorating patients. This review found that simulation-based educational strategies was the most effective educational method for training staff to recognize unwell patients. However, the quality of evidence was low and additional research into simulation-based education is needed.
Bernstein SL, Kelechi TJ, Catchpole K, et al. Worldviews Evid Based Nurs. 2021;18:352-360.
Failure to rescue, the delayed or missed recognition of a potentially fatal complication that results in the patient’s death, is particularly tragic in obstetric care. Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, the authors describe the work system, process, and outcomes related to failure to rescue, and develop intervention theories.
Casey T, Turner N, Hu X, et al. J Safety Res. 2021;78:303-313.
Many factors influence the success of implementation and sustainment of patient safety interventions. Through a review of 38 research articles about safety training, researchers were able to develop a theoretical framework integrating safety training engagement and application of learned skills. They discuss individual, organizational, and contextual factors that influence safety training engagement and application.
Korenstein D, Harris RP, Elshaug AG, et al. J Gen Intern Med. 2021;36:2105-2110.
Provider and patient underestimation of harms of tests and treatments may lead to over treatment. This article presents seven domains of harm of tests and treatment which warrant comprehensive research: (1) physical impairment, (2) psychological distress, (3) social disruption, (4) disruption in connection to healthcare, (5) labeling, (6) financial impact, and (7) treatment burden. Research is especially important in vulnerable patient populations.
Dave N, Bui S, Morgan C, et al. BMJ Qual Saf. 2022;31:297-307.
This systematic review provides an update to McDonald et al’s 2013 review of strategies to reduce diagnostic error.  Technique (e.g., changes in equipment) and technology-based (e.g. trigger tools) interventions were the most studied intervention types. Future research on educational and personnel changes would be useful to determine the value of these types of interventions.
Petrosoniak A, Fan M, Hicks CM, et al. BMJ Qual Saf. 2021;30:739-746.
Trauma resuscitation is a complex, specialized process with a high risk for errors. Researchers analyzed videotapes of in situ simulations to evaluate latent safety events occurring during trauma resuscitation. Themes influencing latent safety events related to physical workspace, mental model formation, equipment, unclear accountability, demands exceeding individuals’ capacity, and task-specific issues.
Mangal S, Pho A, Arcia A, et al. Jt Comm J Qual Patient Saf. 2021;47:591-603.
Interventions to prevent catheter-associated urinary tract infections (CAUTI) can include multiple components such as checklists and provider communication. This systematic review focused on CAUTI prevention interventions that included patient and family engagement. All included studies showed some improvement in CAUTI rates and/or patient- and family-related outcomes. Future research is needed to develop more generalizable interventions.
Brownlee SM, Korenstein D. BMJ. 2021;372:n117.
Overuse of healthcare services can result in financial, physical, and emotional harm to the patient. If patients and clinicians better understood the risk of potential harms due to overuse, preventable harms may be reduced. Research is needed to quantify harm resulting from overuse of healthcare services, including the number of patients harmed and how serious the harms are.  
Lippke S, Derksen C, Keller FM, et al. Int J Environ Res Public Health. 2021;18:2616.
Communication is an essential component of safe patient care. This review of 71 studies found that communication training interventions in obstetrics can improve communication skills and behavior, particularly when combined with team training. The authors identified a lack of evidence regarding the effect of communication trainings on patient safety outcomes and suggest that future research should assess this relationship. Study findings underscore the need for adequate communication trainings to be provided to all staff and expectant mothers and their partners.
Zwaan L, El-Kareh R, Meyer AND, et al. J Gen Intern Med. 2021;36:2943-2951.
Reducing harm related to diagnostic error remains a major focus within patient safety. Based on input from an international group of experts and stakeholders, the authors identified priority questions to advance diagnostic safety research. High-priority areas include strengthening teamwork factors (such as the role of nurses in diagnosis), addressing system factors, and strategies for engaging patients in the diagnostic process.
Avesar M, Erez A, Essakow J, et al. Diagnosis (Berl). 2021;8:358-367.
Disruptive and rude behavior can hinder teamwork and diminish patient safety. This randomized, simulation-based study including attendings, fellows, and residents explored whether rudeness during handoff affects the likelihood for challenging a diagnostic error. The authors found that rudeness may disproportionally hinder diagnostic performance among less experienced physicians.
Contreras J, Baus C, Brandt C, et al. J Am Pharm Assoc (2003). 2021;61:e94-e99.
Naloxone administration is used to mitigate the effects of opioid overdose. The FDA recommends health care professionals educate patients about naloxone when prescribing opioid medications. In this audit of community pharmacists, researchers found that naloxone counseling commonly often excluded concepts important to patient safety, such as assessment of opioid misuse or abuse, possible adverse effects, and naloxone storage.
Traylor AM. Am Psychol. 2021;76:1-13.
The COVID-19 pandemic has dramatically affected the psychological and emotional well-being of health care workers. This article summarizes the COVID-19-related psychological effects on healthcare workers and the detrimental impact on team effectiveness. The authors recommended actions to mitigate the effects of stress on team performance and patient outcomes and discuss how teams can recover and learn from the current crisis to prepare for future challenges.

Passiment M, Wagner R, Weiss KB for the Pursuing Excellence in Clinical Learning Environments: Pathway Leaders Patient Safety Collaborative. Chicago, IL: Accreditation Council for Graduate Medical Education. September 30, 2020. ISBN: 978-1-945365-36-2.

The clinical learning environment (CLE) situates the development of safety behaviors in resident and fellow physicians, students, and staff. This report highlights results of an 18-month collaborative to design tactics that engage resident and fellows in patient safety work through event analysis. Lessons learned supporting success include assessment of the learner experience and dedication of time to enable participation.   
Griffith PB, Doherty C, Smeltzer SC, et al. J Am Assoc Nurse Pract. 2020;33:862-871.
Cognitive debiasing can help reduce cognitive bias and improve clinical decision-making. This scoping review characterized cognitive debiasing strategies used by student health care providers (primarily medical students and residents) to reduce cognitive error. Structured reflection and education initiatives demonstrated the greatest improvements in diagnostic accuracy.
Pelaccia T, Messman AM, Kline JA. Patient Edu Couns. 2020;103:1650-1656.
The hectic and complex environment of emergency care can reduce diagnostic safety. This article discusses clinical reasoning and decision-making strategies used by emergency medicine physicians, contributing factors to diagnostic errors occurring in emergency medicine (e.g., overconfidence, cognitive stress, anchoring bias), and strategies to reduce the risk of error. A previous WebM&M commentary discussed an incident involving diagnostic delay in the emergency department.
Hirsh AT, Anastas TM, Miller MM, et al. Am Psychol. 2020;75:784-795.
Potentially inappropriate opioid prescribing increases risk of patient harm and misuse. This study used videos and written vignettes to explore how patient race and previous opioid misuse behaviors impact providers’ risk assessment for future prescription opioid-related problems. Findings indicate that black patients were perceived by both residents and fellows to be at greater risk for future adverse events and diversion regardless of previous misuse history, suggesting that racial minorities with chronic pain may be vulnerable to unintended consequences of public health efforts to reduce opioid prescribing.
Deacon A, O’Neill T, Delaloye N, et al. Hosp Pediatr. 2020;10:758-766.
This qualitative study used a resuscitation simulation to explore the effect of family presence during resuscitation on team performance. Thematic analyses identified five key factors that are influenced by the presence of a parent during resuscitation – resuscitation environment, affective responses, cognitive responses, behavioral responses, and team dynamics.
Gupta A, Quinn M, Saint S, et al. Diagnosis (Berl). 2021;8:167-175.
This article describes the use of a case-based simulation to explore how physicians reason, create differential diagnoses, and ultimately achieve a correct diagnosis. Participating physicians who achieved the correct diagnosis (herpes zoster) utilized systems-based or anatomic approaches, rather than focuses on life-threatening diagnoses alone, and employed debiasing strategies.