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Renaudin P, Coste A, Audurier Y, et al. Basic Clin Pharmacol Toxicol. 2021;Epub Sep 24.
Pharmacists play an essential role in medication safety through practices such as medication reconciliation and best possible medication history. This observational study found that 20% of patients presenting to surgical units at one French hospital over a two-month period had a medication error. Pharmacists intervened and resolved medication errors related to untreated indications, subtherapeutic dosages, and prescriptions without an indication.
Hyvämäki P, Kääriäinen M, Tuomikoski A-M, et al. J Patient Saf. 2021;Epub Aug 23.
Previous studies have demonstrated health information exchanges (HIE) can improve the quality and safety of care by improving diagnostic concordance and reducing medication errors. This review synthesizes physicians’ and nurses’ perspectives on patient safety related to use of HIE in interorganizational care transitions. Several advantages of and challenges with HIE are detailed.

Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 28, 2021 Publication No. NOT-HS-22-004.

Digital information tools are increasingly relied upon to assist in care communication and decision support, yet their safety hasn’t been fully examined. This announcement highlights AHRQ interest in funding research on the safe use of digital information solutions with a focus on program implementation, system design, and usability.
Mo Y, Eyre DW, Lumley SF, et al. PLoS Med. 2021;18(10):e1003816.
Nosocomial transmission of COVID-19 is an ongoing concern given the pressures faced by hospitals and healthcare workers during the pandemic. This observational study using data from four hospitals in the United Kingdom found that patients with hospital-onset COVID-19 (compared to suspected community-acquired infections) are associated with high risk of nosocomial transmissions to other patients and healthcare workers.
Bernstein SL, Kelechi TJ, Catchpole K, et al. Worldviews Evid Based Nurs. 2021;Epub Sep 6.
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.
Rosenkrantz AB, Siegal D, Skillings JA, et al. J Am Coll Radiol. 2021;18(9):1310-1316.
Prior research found that cancer, infections, and vascular events (the “big three”) account for nearly half of all serious misdiagnosis-related harm identified in malpractice claims. This retrospective analysis of malpractice claims data from 2008 to 2017 found that oncology-related errors represented the largest source of radiology malpractice cases with diagnostic allegations. Imaging misinterpretation was the primary contributing factor.
American Society for Healthcare Risk Management. Louisville, KY, April 4-9, 2022.
This onsite program will cover key patient safety concepts and how to apply them to improve safety. To help prepare attendees for designing and sustaining safety initiatives at their organizations, preconference activities will discuss safety culture, human factors, communication, and leadership development.
Blume KS, Dietermann K, Kirchner‐Heklau U, et al. Health Serv Res. 2021;56(5):885-907.
Nurse staffing levels have been shown to impact patient outcomes. Through an umbrella literature review and expert interviews, researchers developed a list of nurse-sensitive patient outcomes (NSPO). This list provides researchers potential avenues for future studies examining the link between nurse staffing levels and patient outcomes.
Davidson JE, Doran N, Petty A, et al. Am J Crit Care. 2021;30(5):365-374.
The Joint Commission implemented medication management titration standards in 2017, with revisions in 2020. Researchers surveyed critical care nurses about their experiences with medication titration, use of clinical judgment when titrating, nurses’ scope and autonomy, and their moral distress. Of 781 respondents, 80% perceived the titration standards caused delays in patient care and 68% reported suboptimal care, both of which significantly and strongly predicted moral distress.
Svensson J. J Patient Saf. 2021;Epub Aug 5.
Safety and quality of care for psychiatric patients is a relatively understudied area of patient safety research. This scoping review explores patient safety strategies used in psychiatry. The review identified seven key strategies that rely on staff performance, competence, and compliance – (1) risk management, (2) healthcare practitioners, (3) patient observation, (4) patient involvement, (5) computerized methods, (6) admission and discharge, and (7) security. These strategies primarily target reductions in suicide, self-harm, violence, and falls.
O’Dowd E, Lydon S, Lambe KA, et al. Fam Pract. 2021;Epub Sep 20.
Patient complaints can identify opportunities for patient safety improvement. This study explored whether an existing tool for measuring the severity of patient complaints – the Healthcare Complaints Analysis Tool – can effectively analyze complaints specific to general practice. Key issues identified by the study involved relationships (e.g., communication, patient rights) as well as clinical and management issues.

ISMP Medication Safety Alert! Acute care edition. October 21, 2021;26(21):1-3.

Shortcuts in automated data entry behaviors have potential to result in errors. This article discusses search term length requirements for automated dispensing cabinets and the importance of doing a proactive failure analysis prior to implementing any system conditions to minimize unintended consequences of the rules that could detract from safety.
Finney RE, Czinski S, Fjerstad K, et al. J Pediatr Nurs. 2021;61:312-317.
The term “second victim” refers to a healthcare professional who was involved in a medical error and subsequently experiences psychological distress. An American children’s hospital implemented a peer support program for “second victims” in 2019. Healthcare providers were surveyed before and after implementation of the program with results showing the highest ranked option for support following a traumatic clinical event is peer support. Most respondents indicated they were likely to use the program if a future clinical event were to occur.
Schlichtig K, Dürr P, Dörje F, et al. Clin Pharmacol Ther. 2021;110(4):1075-1086.
Building on prior research, this study found that medication errors are common in patients starting new oral anticancer therapy. Nearly two-thirds of these medication errors involved concomitantly administered medications (e.g., other prescribed drugs, over-the-counter medications).

Manchester, UK: Parliamentary and Health Service Ombudsman; October 2021.

This report examines a premature infant death associated with failings of antibiotic administration, deterioration recognition and action on family concerns both during treatment and post-incident. The report issues a series of recommendations building on standard remediation guidance in the United Kingdom.
Orenstein EW, Kandaswamy S, Muthu N, et al. J Am Med Inform Assoc. 2021;Epub Oct 20.
Alert fatigue is a known contributor to medical error. In this cross-sectional study, researchers found that custom alerts were responsible for the majority of alert burden at six pediatric health systems. This study also compared the use of different alert burden metrics to benchmark burden across and within institutions.