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Simpson M, Kovach CR. Res Gerontol Nurs. 2021;Epub Oct 5.
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.
Organization: Institute for Healthcare Improvement (IHI)
Event Description: This three day annual meeting focuses on providing smarter, safer care for all patients wherever it is provided - from the hospital to outpatient settings to the home. 
Event Location: In Person: Dallas, TX
Date: May 16–18, 2022
Event Fee: Fee Associated
CE or CME Offered?
Organization: American Congress of Obstetricians and Gynecologists (ACOG)
Event Description: This three-day in person conference will center around four tracks: obstetrics, gynecology, professional development, and office practice with the theme: Reconnect, Recharge, Reset.
Event Location: In-Person: San Diego, CA
Date: May 6-8, 2022
Event Fee: Fee Associated
CE or CME Offered? Yes
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.

JAMA. 2021. 

Diagnostic excellence achievement is becoming a primary focus in health care. This article series covers diagnosis as it relates to the Institute of Medicine quality domains, clinical challenges, and priorities for improvement across the system.
O’Connor P, O’Malley R, Lambe KA, et al. Int J Qual Health Care. 2021;Epub Oct 9.
Patient safety incidents occurring in prehospital care settings are gaining increasing attention. This systematic review including both peer-reviewed studies and grey literature found that the incidence rate of prehospital patient safety incidents is similar to hospital rates. The authors identified an average of 5.9 patient safety incidents per 100 records/transports/patients occurring in prehospital care; approximately 15% of these incidents resulted in patient harm. The authors discuss methodological challenges to preshopital care research and make recommendations for future studies.
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.
Freeman K, Geppert J, Stinton C, et al. BMJ. 2021;374:n1872.
Artificial intelligence (AI) has been used and studied in multiple healthcare processes, including detecting patient deterioration and surgical decision making. This literature review focuses on studies using AI to detect breast cancer in mammography screening practice. The authors recommend additional prospective studies before using artificial intelligence in clinical practice. 
Manias E, Street M, Lowe G, et al. BMC Health Serv Res. 2021;21(1):1025.
This study explored associations between person-related (e.g., individual responsible for medication error), environment-related (e.g., transitions of care), and communication-related (e.g., misreading of medication order) medication errors in two Australian hospitals. The authors recommend that improved communication regarding medications with patients and families could reduce medication errors associated with possible or probable harm.

Jewett C. Kaiser Health News. November 4, 2021.

Nosocomial infection is a primary concern due to the COVID pandemic. This news story examines instances when inpatients contracted, and sometimes died of, COVID-19 while receiving care for a different condition. It summarizes the challenges associated with collecting adequate data that completely document nosocomial spread of COVID-19 and its impact on patient outcomes.
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.
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).

Rockville, MD: Agency for Healthcare Research and Quality; 2021.

AHRQ’s Hospital Survey on Patient Safety Culture™ (SOPS®) ask health care providers and staff about the extent to which their organizational culture supports patient safety. 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 workplace culture supports workplace safety for providers and staff. Included with the data set is a report of the pilot test of the finding. You can learn more about the supplemental items and can register for a webcast introducing the Workplace Safety items here: Surveys on Patient Safety Culture™ (SOPS®) | Agency for Healthcare Research and Quality (ahrq.gov)  
Krishnan S, Wheeler KK, Pimentel MP, et al. J Healthc Risk Manag. 2021;Epub Oct 28.
Incident reporting systems are used to detect patient safety concerns and determine potential causes and opportunities for improvements. In the perioperative setting of one hospital, insufficient handoffs were the most common event type in the “coordination of care” category. Use of structured handoffs is recommended to improve communication and patient safety.
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.
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.
Dunbar NM, Kaufman RM. Transfusion (Paris). 2021;Epub Nov 3.
Wrong blood in tube (WBIT) errors can be classified as intended patient drawn/wrong label applied or wrong patient/intended label applied. In this international study, errors were divided almost evenly between the two types and most were a combination of protocol violations (e.g. technology not used or not used appropriately) and slips/lapses (e.g., registration errors). Additional contributory factors and recommendations for improvement are also discussed.

Office of the Federal Register, National Archives and Records Administration. Fed Register. November 3, 2021;(86):60883-60893.

Patient suicide attempts are considered never events. This funding announcement calls for program applications to motivate suicide prevention strategy implementation in the indigenous peoples’ community. The effort anchors on the Zero Suicide initiative to address unique challenges presented by the Indian health system. 
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.

Irvine, CA: The Patient Safety Movement Foundation; 2021.

Blood transfusion mistakes can result in severe adverse events. This report shares successful strategies to reduce transfusion process errors. The document highlights patient assessment, process standardization, and cross-disciplinary team building as steps toward improving transfusion safety.