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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.

Uhl S, Siddique SM, McKeever L, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2021.  AHRQ Publication No. 21(22)-EHC035.

Patient malnutrition is an underrecognized threat to patient safety. This report provides a comprehensive evidence analysis on the patient malnutrition literature, the relationship of in-hospital malnutrition to patient harm across patient groups and tactics for measurement of the problem to design and assess the impact of interventions.
Burrus S, Hall M, Tooley E, et al. Pediatrics. 2021;148:e2020030346.
Based on analysis of four years of data submitted to the Child Health Patient Safety Organization (CHILDPSO), researchers sought to identify types of serious safety events and contributing factors. Three main groups of serious safety events were identified: patient care management, procedural errors, and product or device errors. Contributing factors included lack of situational awareness, process failures, and failure to communicate effectively.
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.
Keister LA, Stecher C, Aronson B, et al. BMC Public Health. 2021;21:1518.
Constrained diagnostic situations in the emergency department (ED), such as crowding, can impact safe care. Based on multiple years of electronic health record data from one ED at a large U.S. hospital, researchers found that providers were significantly less likely to prescribe opioids during constrained diagnostic situations and less likely to prescribe opioids to high-risk patients or racial/ethnic minorities.
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.
Pati D, Valipoor S, Lorusso L, et al. J Patient Saf. 2021;17:273-281.
Decreasing inpatient falls requires improvements in both processes of care and the care environment. This integrative review found that some elements of the built environments have not been rigorously examined and concluded that objective and actionable knowledge on physical design solutions to reduce falls is limited.  

Shannon EM, Zheng J, Orav EJ, et al. JAMA Network Open. 2021:4(3);e213474.

This cross-sectional study examined whether racial/ethnic disparities in interhospital transfers (IHT) for common medical diagnoses such as heart failure, acute myocardial infarction, stroke, and sepsis, impact mortality outcomes. The authors analyzed 899,557 patients and reported that Black patients had lower odds of IHT compared to White patients, while Hispanic patient had higher odds of IHT compared with White patients. The authors propose several possible explanations including differences in Black and Hispanic willingness to transfer, impact of insurance status and reimbursement rates, coding inaccuracies, and other complex dynamics for their findings.
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.
Turner K, Staggs V, Potter C, et al. BMJ Qual Saf. 2020;29:1000-1007.
Fall prevention remains a patient safety priority. This article describes how fall prevention strategies are being implemented and operationalized across 60 hospitals in the United States. While many hospitals employed recommended strategies identified, implementation was suboptimal at times – for example, interdisciplinary fall committees were common but rarely included physicians.
Donovan AL, Aaronson EL, Black L, et al. Jt Comm J Qual Patient Saf. 2021;47:23-30.
Patient suicide, attempted suicide, or self-harm are considered ‘never events.’ This article describes the development and implementation of a safety protocol for emergency department (ED) patients at risk for self-harm, including the creation of safe bathrooms and increasing the number of trained observers in the ED. Implementation of the protocol was correlated with lower rates of self-harm.  
Salvador RO, Gnanlet A, McDermott C. Personnel Rev. 2020;50:971-984.
Prior research suggests that functional flexibility has benefits in several industries but may carry patient safety risks in healthcare settings. Using data from a national nursing database, this study examined the effect of unit-level nursing functional flexibility on the incidence of hospital-acquired pressure ulcers. Results indicate that higher use of functionally flexible nurses was associated with a higher number of pressure ulcers, but this effect was moderated when coworker support within the unit was high.
Demaria J, Valent F, Danielis M, et al. J Nurs Care Qual. 2021;36:202-209.
Little empirical evidence exists assessing the association of different nursing handoff styles with patient outcomes. This retrospective study examined the incidence of falls during nursing handovers performed in designated rooms away from patients (to ensure confidentiality and prevent interruptions and distractions). No differences in the incidence of falls or fall severity during handovers performed away from patients versus non-handover times were identified.
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.
O’Donovan R, McAuliffe E. BMC Health Serv Res. 2020;20:810.
Organizational cultures that encourage psychological safety have been shown to increase safe healthcare. The authors used survey, observational, and interview data to explore psychological safety within four healthcare teams in one hospital. While survey results indicated a high level of psychological safety, observations and interviews identified examples of situations resulting in lower levels of psychological safety, such as absence of learning behavior, low levels of support from other team members, and lack of familiarity among team members.
Lau VI, Priestap FA, Lam JNH, et al. J Intensive Care Med. 2020;35:1067-1073.
Many factors can contribute to early, unplanned readmissions among critical care patients. In this prospective cohort study, adult patients who were discharged directly home after an ICU admission were followed for 8 weeks post-discharge to explore the predictors of adverse events and unplanned return visits to a health care facility. Among 129 patients, there were 39 unplanned return visits. Researchers identified eight predictors of unplanned return visits including prior substance abuse, hepatitis, discharge diagnosis of sepsis, ICU length of stay exceeding 2 days, nursing workload, and leaving against medical advice.  
Pulia M, Wolf I, Schulz L, et al. West J Emerg Med. 2020;21:1283-1286.
Antimicrobial stewardship is one strategy to improve antibiotic use to reduce hospital-acquired infections. In this editorial, the authors discuss negative effects of COVID-19 on antimicrobial resistance and antibiotic stewardship in the emergency department (ED) and approaches for optimizing ED stewardship during the pandemic.  
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.
Bittman J, Nijjar AP, Tam P, et al. J Patient Saf. 2020;16:e169-e173.
This study found that two early warning scores – the Modified Early Warning Score (MEWS) and the National Early Warning Score (NEWS) – can predict patients at risk of deterioration and who will need to be seen by a physician overnight. The authors conclude that use of such early warning scores may be useful for improving handoffs and resource allocation for overnight care.