The PSNet Collection

Empowering Patients and Supporting Health Care Providers—New Avenues for High Quality Care and Safety.

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Rimondini M, Busch IM, eds. Int J Environ Res Public Health. 2021;18.

Patient/clinician relationships supported by organizational culture and individual wellness efforts are core to the provision of high-quality care and process improvement engagement. This article collection highlights trainee attitudes about patient safety and how respect and support for enhancing the care experience of both patients and those who care for them are foundational to safe, effective care.

The 2020 John M. Eisenberg Patient Safety and Quality Awards.

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Jt Comm J Qual Patient Saf. 2021;47(8):463-488.

The Eisenberg Award honors individuals and organizations who have made significant advancements in the pursuit of safe, high-quality health care. The 2020 honorees are Dr. David Gaba; Veterans Health Administration Rapid Naloxone Initiative, Washington, DC, and Northwestern Medicine Academy for Quality and Safety Improvement, Chicago IL.

Intravenous admixture preparation considerations, Parts 9-A and 9-B: error prevention in intravenous admixture preparation.

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Allen LV, Jr. Int J Pharm Compd. 2021;25:131-139; 222-229.

Intravenous admixture compounding is a complex activity that harbors risks for patients and health care staff. This two-part series reviews the types of errors that compromise the safety of compounding practices, steps in the process where they occur and prevention tactics.

Medical Residents and Burnout

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Coverdale J, West CP, Roberts LW, eds. Acad Med. 2021;96(5):611-769;e14-e21.

Medical training is a demanding experience that impacts a learner’s ability to provide safe care, cope, and remain healthy. This issue covers a range of topics exploring the mental health consequences of residency, factors influencing well-being, and approaches to help individuals successfully navigate the stress of residency.

Quality and Safety in Health Care.

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Harolds JA, Harolds LB. Clin Nucl Med. 2015–2021.

This monthly commentary explores a wide range of subjects associated with patient safety, such as infection prevention, surgical quality improvement, and high reliability organizations.

Two decades since To Err Is Human: progress, but still a "chasm".

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Dzau VJ, Shine KI. JAMA. 2020;324:2489-2490.

To Err is Human and Crossing the Quality Chasm changed the trajectory of improvement efforts worldwide. This editorial and the associated viewpoints outline the impact of the reports on global, COVID-19, anesthesiology, and ambulatory care.

Patient Safety

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Zheng F ed. Surg Clin North Am. 2021;101(1):1-160.

Surgical safety is a recognized area of emphasis in patient safety improvement. Articles in this special issue cover topics such as human factors, checklists, teamwork, and telemedicine as a safe support mechanism.

Missed or Rationed Nursing Care.

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J Nurs Manag. 2020;28(8): i-iv, 1767-2275.

Incomplete nursing care is known to affect care quality and safety. This special issue documents the global problem of missed or rationed nursing care in a variety of settings and countries. Articles featured in this special issue examine systemic issues, explore interventions, and evaluate measurement tools.

Digital Health and Patient Safety.

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Health Informatics J. 2020;26:181-189;576-591;683-718;1017-1042;2295-2299;3123-3162.

This special collection examines the use of novel health information technology (HIT) to promote patient safety and challenges in examining the impact of those technologies. Articles featured in this issue include a focus on qualitative approaches to evaluating the impact of HIT on patient safety, particularly through a sociotechnical lens.

COVID-19: The Diagnostic Challenge.

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Diagnosis (Berl). 2020;7(4):345-411.

COVID-19 is a novel coronavirus that harbors a variety of diagnostic, treatment, and management hurdles. This special issue covers a variety of clinical topics including optimal diagnostic methods, near misses, and diagnostic accuracy.

Management of Operating Room Critical Events.

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Hannenberg AA, ed. Anesthesiol Clin. 2020;38(4):727-922.

Anesthesiology critical events are uncommon, and yet they have great potential for harm. This special issue focuses on management of, and preparation for, perioperative critical events and rescue should they occur. The authors highlight simulation training, debriefing, and cognitive aids as methods for improving safety in the operating room.

High-Performance Work Systems in Health Care Management: Parts 1-5.

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Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.

In this continuing series, high-performance work practices are explored and defined through literature review, case analysis, and research. The authors summarize findings and discuss how best practices can influence quality, safety, and efficiency outcomes. Topics covered include speaking up, central line infection prevention, and business case development.

Becoming a High Reliability Organization.

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VHA Forum. Summer 2020;1-12.

High reliability attainment is a stated goal for health care organizations. This special issue covers established initiatives at the United States Veterans Health Administration that draw from high reliability principles to improve care. Topics covered include evaluation priorities, safe patient handling and diagnostic safety.

Advancing Patient Safety: Reviews From the Agency for Healthcare Research and Quality's Making Healthcare Safer III Report.

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J Patient Saf. 2020;16:s1-s56.

The patient safety evidence base has been growing exponentially for two decades with noted expansion into the non-acute care environment. This special issue highlights eight articles illustrating the range of practices examined in the AHRQ Making Healthcare Safer III report, including rapid response teams and failure to rescue, deprescribing practices and opioid stewardship.

Patient Safety.

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Levett-Jones T, ed. Clin Sim Nurs. 2020;44(1):1-78; 2020;45(1):1-60.

Simulation is a recognized technique to educate and plan to improve care processes and safety. This pair of special issues highlights the use of simulation in nursing and its value in work such as communication enhancement, minority population care, and patient deterioration.

Older Adults and COVID-19: Implications for Aging Policy and Practice.

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Miller EA, ed. J Aging Soc Policy. 2020;32(4-5):297-535.

The COVID-19 crisis has disproportionally impacted the lives of older adults, their caregivers, and the communities in which they live. This special issue includes articles examining topics such as the role of policies affecting this patient population, effective communication with older adults and concerns associated with long-term care facilities.

The 2019 John M. Eisenberg Patient Safety and Quality Awards.

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Jt Comm J Qual Saf. 2020;46(7):PI-II:2020;371-399.

The Eisenberg Awards honor individuals and organizations who have had noteworthy impacts on patient safety and quality improvement. This article collection highlights the work of the 2019 honorees: Gordon D. Schiff, MD; WellSpan Health, York, Pennsylvania; and HCA Healthcare, Nashville, Tennessee.

Implementing, Studying, and Reporting Health System Improvement in the Era of Electronic Health Records.

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Auerbach AD, Bates DW, Rao JK, et al, eds. Ann Intern Med. 2020;172(11_Supp):S69-S144.

Research and error reporting are important strategies to uncover problems in health system performance. This special issue highlights vendor transparency and context as important areas of focus to ensure electronic health records (EHR) research and reporting help improve system reliability. The articles cover topics such as a framework for research reporting, design of randomized controlled trials for technology studies, and designing research on patient portal enhancement.

Patient Safety

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Nicklin W, Hughes L, eds. Patient Safety. Healthc Q. 2020;22(Sp2):1-128.

Articles in this special issue report on initiatives undertaken by the Canadian National Patient Safety Consortium with a focus on the effect patient partnerships on initiative priority areas including never events, safety culture and homecare safety improvements.

20 years later: to err is a leadership failure.

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Castellucci M, Meyer H. Modern Healthcare: November 11, 2019;49:18-22;28-30;32-34.

This special segment shares commentaries and online content that summarize growth and lack of progress in various areas of patient safety since To Err is Human was published. Topics covered include the ineffectiveness of current measures and lack of leadership commitment to the issue. Patient stories and organizational efforts to improve safety are covered in the online segments.

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