The PSNet Collection

Patient and caregiver factors in ambulatory incident reports: a mixed-methods analysis.

Save to Library

Sharma AE, Huang B, Del Rosario JB, et al. BMJ Open Qual. 2021;10: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.

Debriefing for Clinical Learning

Save to Library

November 18, 2021

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.

Review of reported adverse events occurring among the homeless veteran population in the Veterans Health Administration.

Save to Library

Soncrant C, Mills PD, Pendley Louis RP, et al. J Patient Saf. 2021;17: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.

Prevention of failure to rescue in obstetric patients: a realist review.

Save to Library

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.

Supervision, interprofessional collaboration, and patient safety in intensive care units during the COVID-19 pandemic.

Save to Library

Hennus MP, Young JQ, Hennessy M, et al. ATS Sch. 2021;2:397-414.

The surge of patients during the COVID-19 pandemic forced the redeployment of non-intensive care certified staff into intensive care units (ICU). This study surveyed both intensive care (IC)-certified and non-IC-certified healthcare providers who were working in ICUs at the beginning of the pandemic. Qualitative synthesis identified five themes related to supervision; quality and safety of care; collaboration, communication, and climate; recruitment, scheduling and team composition, and; organization and facilities. The authors provide recommendations for future deployments.

Critical care simulation education program during the COVID-19 pandemic.

Save to Library

Leibner ES, Baron EL, Shah RS, et al. J Patient Saf. 2022;18:e810-e815.

During the first surge of the COVID-19 pandemic, a rapid redeployment of noncritical care healthcare staff was necessary to meet the unprecedented number of patients needing critical care. A New York health system developed a multidisciplinary simulation training program to prepare the redeployed staff for new roles in the intensive care unit (ICU). The training included courses on management of a patient with acute decompensation with COVID-19, critical care basics for the non-ICU provider, and manual proning of a mechanically ventilated patient.

PACT Collaborative: Pathway to Accountability, Compassion and Transparency.

Save to Library

Ariadne Labs, Brigham and Women’s Hospital, Harvard TH Chan School of Public Health.

Communication and Resolution Programs (CRP) are a promising strategy for managing the aftermath of medical harm. This 18-month collaborative will help participants engage leadership, implement CRP processes, build patient partnerships and establish measurement approaches to gauge the success of CRP efforts. The program will launch in 2022 and applicants will be informed of participation status no later than December 10, 2021.

Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds.

Save to Library

Klimmeck S, Sexton BJ, Schwendimann R. Jt Comm J Qual Patient Saf. 2021;47:783-792.

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.

Acute care nurses' perceptions of leadership, teamwork, turnover intention and patient safety - a mixed methods study.

Save to Library

Zaheer S, Ginsburg LR, Wong HJ, et al. BMC Nurs. 2021;20:134.

A culture of safety is essential to reducing medical errors and improving patient safety. In this mixed-methods study, researchers found that acute care nurses’ perceptions of senior leadership, teamwork, and turnover intention were associated with perceived patient safety.

Therapeutic duplication on the general surgical wards.

Save to Library

Huynh I, Rajendran T. BMJ Open Qual. 2021;10:e001363.

Unintentional therapeutic duplication can lead to life-threatening complications. As part of a quality improvement project on a surgical ward, staff were educated about the risks of therapeutic duplication and strategies to decrease it. After one month of education and reminders, the rate of therapeutic duplication decreased by more than half.

Association of simulation training with rates of medical malpractice claims among obstetrician-gynecologists.

Save to Library

Schaffer AC, Babayan A, Einbinder JS, et al. Obstet Gynecol. 2021;138:246-252.

Adverse events in obstetrics threaten the safety of both maternal and infant patients. This study identified a significant reduction in malpractice claims among obstetrician-gynecologists after participation in simulation training focused on team training and crisis management.

Training Program for Nurses on Shift Work and Long Work Hours.

Save to Library

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.

Safety events impacting hospitalized patients following motor vehicle crashes: a qualitative study of reports from Pennsylvania hospitals.

Save to Library

Kukielka E. Patient Saf. 2021;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.

Clinical Learning Environment Review (CLER) Program.

Save to Library

Accreditation Council for Graduate Medical Education.

Many graduate medical education programs have instituted patient safety didactics or online courses to meet accreditation standards, but these are likely insufficient in the face of real-world practices commonly witnessed by trainees in clinical settings. Recognizing the importance of this hidden curriculum on shaping trainees' behaviors, the Accreditation Council for Graduate Medical Education (ACGME) created the Clinical Learning Environment Review (CLER) program to evaluate teaching institutions in six focus areas: patient safety, quality improvement, transitions in care, supervision, duty hours, and professionalism. Between June 2017-February 2020, the ACGME visited more than 566 ACGME-accredited institutions as part of this program. According to ACGME leaders, the early findings show an overall lack of trainee engagement in the systems-based practices. Available on the Web site, the latest CLER report describes discoveries from the program and provides a guide for teaching institutions to create clinical environments that support patient safety training and practices.

Interventions to improve communication at hospital discharge and rates of readmission: a systematic review and meta-analysis.

Save to Library

Becker C, Zumbrunn S, Beck K, et al. JAMA Netw Open. 2021;4:e2119346.

Discharge from the hospital represents a vulnerable time for patients. This systematic review assessed the impact of discharge communication on hospital readmissions, adherence to treatment regimen, patient satisfaction, mortality, and emergency department visits 30 days after hospital discharge. Findings suggest that improved communication at discharge reduced 30-day hospital readmissions and increased adherence to treatment regimen.

Dual surgeon operating to improve patient safety.

Save to Library

Ellis R, Hardie JA, Summerton DJ, et al. Surg. 2021;59:752-756.

Many non-urgent, non-cancer surgeries were postponed or canceled during COVID-19 surges resulting in a potential loss of surgeons’ “currency”. This commentary discusses the benefits of, and barriers to, dual surgeon operating as a way to increase currency as elective surgeries are resumed.

When less is more: the role of overdiagnosis and overtreatment in patient safety.

Save to Library

Kamzan AD, Ng E. Adv Pediatr. 2021;68:21-35.

Overuse, overdiagnosis, and overtreatment pose a continuing threat to patient safety. Citing several contributors to overuse at the system, clinician, and patient levels, this commentary discusses potential solutions including the Choosing Wisely campaign and patient education.

A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency.

Save to Library

Warm EJ, Ahmad Y, Kinnear B, et al. Acad Med. 2021;96:1268-1275.

Technical and procedural skills are an important emphasis of medical training. This article briefly summarizes the “as low as reasonably achievable” (ALARA) approach, which was developed for the nuclear industry and has been used in radiology. The authors outline how ALARA risk standards can be adapted by training program directors to measure procedural competency and assess and reduce bedside procedural risks.

Parenteral nutrition safety.

Save to Library

Mirtallo JM, Ayers P. Pharmacy Practice News. September 7, 2021;48(9):17-20.

Parenteral nutrition (PN) processes contain various steps that are prone to errors resulting in patient harm. This article discusses standardization as a strategy to reduce the potential for missteps and shares resources for process evaluation to improve PN reliability and safety.

Curated Libraries

Maternal Safety

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users