Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
1 - 20 of 11960
Walton E, Charles M, Morrish W, et al. J Patient Saf. 2021;Epub Sep 28.
Dialysis is a common procedure that carries risks if not performed correctly. This study analyzed dialysis-related bleeding events reported to the Veterans Health Administration Patient Safety Authority over an 18-year period. The analysis identified four areas of focus to reduce bleeding events – (1) the physical location and equipment used, (2) staff commitment to standardization and attention to detail (to reduce unwitnessed bleeding events), (3) mental status of the patient, and (4) the method for hemodialysis delivery.
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.
Halsey-Nichols M, McCoin N. Emerg Med Clin North Am. 2021;39(4):703-717.
Diagnostic errors among patients presenting to the emergency department (ED) with abdominal pain are common. This article summarizes the factors associated with missed diagnoses of abdominal pain in the ED, the types of abdominal pain that are commonly misdiagnosed, and recommended steps for discharging a patient with abdominal pain without a final diagnosis.
Klasen JM, Teunissen PW, Driessen EW, et al. Med Teach. 2021;Epub Oct 13.
Previous research has found that error permission (allowing errors to arise naturally and not preventing them) is a common strategy used in clinical training. This qualitative study with supervising physicians found that decisions to allow residents to fail are often made in the moment and are influenced by the patient, supervisor, trainee, and environmental factors.
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.  

Sentinel Event Alert. Nov 10 2021;(64):1-7.

Health care disparities emerging as a core patient safety issue. This alert introduces strategies to align organizational and patient safety strategic goals, such as collection and analysis of community-level performance data, adoption of diversity and inclusion as a precursor to improvement, and development of business cases to support inequity reduction initiatives.

Chicago, IL: National Collaborative for Improving the Clinical Learning Environment; 2021. ISBN: 9781945365416.

Health care provision requires continuous learning to enhance skills, collaboration, and system awareness. This report discusses characteristics of an environment that nurtures learning across disciplines in health care. It centers on 6 areas of focus: patient safety, quality, teaming, supervision, well-being, and professionalism.

December 16, 2021. 

The release of the Workplace Safety supplemental items for use in conjunction with the AHRQ Hospital Survey on Patient Safety Culture™ helps hospitals assess how their organizational culture supports workplace safety for providers and staff. This webinar provided background on the importance of workplace safety and introduce the Workplace Safety supplemental items.

Prasad V, Medpage Today. November 16, 2021.

The issue of system versus individual accountability can challenge the orientation of safety improvement efforts. This opinion piece discusses the importance of physician recognition of decision making mistakes and the downside of the evolution of morbidity and mortality conferences away from that approach.
Moy E, Hausmann LRM, Clancy CM. Am J Med Qual. 2022;37(1):81-83.
Shortcomings in health equity represent systemic weaknesses in health care. This commentary suggests that actions to reduce disparities be added to the components of high reliability organizations (HRO) to facilitate an expansion of the HRO concept to address the threat to patient safety that inequity represents.
Simpson M, Kovach CR. Res Gerontol Nurs. 2021;14(6):293-304.
This prospective study explored iatrogenic events emerging among older adults in one post-acute care hospital. Researchers found that most new problems were exacerbations of preexisting conditions rather than problems stemming from the primary reason for hospitalization. Findings indicate risk factors such as comorbidities or functional level may not be useful in determining the likelihood of new problems or iatrogenic events during post-acute rehabilitation.
Townsend T, Cerdá M, Bohnert AS, et al. Health Aff (Millwood). 2021;40(11):1766-1775.
Misuse of prescription opioids represents a serious patient safety issue. Using commercial claims from 2014 - 2018, researchers examined the association between the 2016 CDC guidelines to reduce unsafe opioid prescribing and opioid dispensing for patients with four common chronic pain diagnoses. Findings indicate that the release of the 2016 guidelines was associated with reductions in the percentage of patients receiving opioids, average dose prescribed, percentage receiving high-dose prescriptions, number of days supplied, and the percentage of patients receiving concurrent opioid/benzodiazepine prescriptions. The authors observe that questions remain about how clinicians are tailoring opioid reductions using a patient-centered approach.
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.
Ly DP. Ann Emerg Med. 2021;78(5):650-657.
A common type of diagnostic error is availability bias, or diagnosing a patient based on experiences with past similar cases. This study examined whether an emergency physician’s recent experience of a patient presenting with shortness of breath and diagnosed with pulmonary embolism increased subsequent pulmonary embolism diagnoses. While pulmonary embolism diagnosis did increase over the following ten days, that effect did not persist over the 50 days following the first 10 days.
McNiven B, Brown AD. Jt Comm J Qual Patient Saf. 2021;47(12):809-813.
Errors and near misses reported via incident reporting systems can highlight emerging patient safety concerns; however, rates of reporting remain low. In this comparison study of web-based and interactive voice response systems (IVRS), the mean number of reports was higher for IVRS and length of time to complete the report was lower.
Robinson-Lane SG, Sutton NR, Chubb H, et al. J Am Med Dir Assoc. 2021;22(11):2245-2250.
The COVID-19 pandemic has exacerbated racial and ethnic disparities in healthcare. This study used registry data to examine racial and ethnic disparities in post-discharge outcomes among patients hospitalized with COVID-19. Findings indicate that Black patients may be more vulnerable to COVID-19-related complications (e.g., higher 60-day readmission rates) and extended recovery periods (e.g., longest delays in returning to work).
Soncrant C, Mills PD, Pendley Louis RP, et al. J Patient Saf. 2021;17(8):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.
Upadhyay S, Stephenson AL, Weech-Maldonado R, et al. J Patient Saf. 2021;Epub Sep 28.
This longitudinal study concluded that culturally competent hospitals have better patient safety culture than other hospitals. Based on survey data, results indicate that hospitals with higher levels of engagement in diversity programs had higher perceptions of management support for safety, teamwork across units, and nonpunitive responses.
Urban D, Burian BK, Patel K, et al. Ann Surg. 2021;2(3):e075.
The WHO surgical safety checklist has been implemented in healthcare systems around the world. Survey responses from 2,032 surgical team members from high-income countries suggest that most respondents perceive the checklist as enhancing patient safety, but that not all team members are engaging with its use or feel confident in their role in the checklist process.