The PSNet Collection

Bias in mental health diagnosis gets in the way of treatment.

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Garb HN. Psyche. March 22, 2022.

A wide array of biases can affect clinical judgement and contribute to diagnostic error. This article discusses the impact of implicit biases, test inaccuracy, and data weaknesses in diagnosis of mental health conditions in both children and adults. The author provides recommendations for clinicians and researchers to reduce the impact of bias on diagnosis.

Ensuring critical instruments and devices are appropriate for reuse.

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Quick Safety. February 14, 2022;(64):1-3.

Complete, appropriate reprocessing and sterilization of reusable medical instruments and devices is vital for infection prevention. This newsletter article shares actions to improve infection prevention, including standardized examination processes, infection preventionist involvement, and training focused on the safety impacts of incomplete processing and inappropriate reuse of single use items.

Nowhere is safe: record number of patients contracted Covid in the hospital in January.

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Levy R, Vestal AJ. Politico. February 19, 2022.

Transmission of COVID-19 in the health care setting continues to be a concern. This article discusses an analysis of US government statistics tracking hospital-acquired COVID-19 infections and reasons that control efforts may be lagging, which include visitor masking choices and health care worker return to work post-COVID-19 behaviors.

Start the year off right by addressing these top 10 medication safety concerns from 2021

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Medication Safety Alert! Acute care edition. January 27, 2022;27(2):1-6.

Medication errors are a consistent threat to safe patient care. This newsletter article analyzes events submitted to the Institute for Safe Medication Practices in 2021 and highlights those that are COVID-related or common, yet preventable, if practice recommendations and system improvements are applied.

COVID Risk In Hospitals.

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Weber L, Jewett C. Kaiser Health News. 2021-2022.

The infectious nature of COVID continues to impact the safety of hospitalized patients. This article series examines factors contributing to hospital-acquired COVID-19 infection that include weaknesses in oversight, patient legal protections, and documentation.

Curated Libraries

Medication/Drug Errors

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.

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ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares reported vaccine errors and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.

Curated Libraries

Maternal Safety

'There is a real cost’: as Covid shows, barring bedside visitors from ICU deprives patients of the best care.

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Renault M. Stat. July 28, 2021.

Care and safety concerns for patients, families, and clinicians continue to be challenged by COVID-19. This article discusses the unintended consequences of isolation practices during the pandemic as a contributor to patient harm due to resultant family support barriers and loneliness they caused.

A tragic death shows how ERs fail patients who struggle with addiction.

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Pattani A. NPR Shots. July 14, 2021.

Patients with substance abuse disorders face challenges to safe, effective care. This news story highlights how pressures associated with access and cost affect identification of these vulnerable patients and their ability to receive treatment after they arrive at an emergency room.

Administration of concentrated potassium chloride for injection during a code: still deadly!

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ISMP Medication Safety Alert! Acute care edition. June 3, 2021; 26(11): 1-5.

Concentrated potassium chloride is a high-alert medication for which dosing errors are particularly injurious. This article shares the root causes of IV-push missteps with this medication during a code. Recommendations for improvement shared center on team characteristics and communication.

Cancer diagnoses delayed among prisoners in Washington state.

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Medscape Medical News. May 12, 2021.

Delays and mistakes in health care for distinct patient populations hold improvement lessons for the broader system. This news story highlights problems in correctional system cancer diagnoses and treatment that may indicate other types of prison care delivery problems.

More can be done to alleviate errors associated with pharmaceutical product labeling and packaging.

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ISMP Medication Safety Alert! Acute Care Edition. May 6, 2021;26(9):1-4.

Look-alike labeling is a known contributor to medication errors. This article summarizes common factors resulting in packaging and labeling concerns. Recommendations for improvement include partnerships with industry regarding the use of risk management practices to improve the accuracy of labeling prior to product launch.

A recurring call to action: every healthcare organization needs a medication safety officer!

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ISMP Medication Safety Alert! Acute care edition. February 25, 2021;26(4);1-4.

Leadership roles exist in a variety of clinical areas to support safe, effective practice. This article introduces medication safety officers as a targeted strategy to enhance implementation of initiatives addressing challenges in reducing the safety of pharmaceutical therapies and direct organizational learning from medication errors.

The plague year. The mistakes and the struggles behind America’s coronavirus tragedy.

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Wright L. New Yorker. January 4, 2021;96(463):20-59.

Uncertainty, misinformation, management gaps, and rapid escalation undermine crisis response effectiveness. This article illustrates system, leadership, and process failures that contributed to harms associated with the COVID-19 pandemic.

Learning from influenza vaccine errors to prepare for COVID-19 vaccination campaigns.

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ISMP Medication Safety Alert! Acute care edition. November 19, 2020;25(23):1-6.

Safety professionals encourage learning from errors to enhance the safe use of new processes and products. This article reviews vaccine error experiences and provides insight for the implementation of the COVID vaccine to help practitioners plan and activate safe vaccination processes.

FDA Advise-ERR: reported medication errors with Veklury (remdesivir) emergency use authorization.

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ISMP Medication Safety Alert! Acute care edition. September 10, 2020;25(18)

This alert discusses medication errors that have been reported to the Food and Drug Administration involving the preparation, administration, and storage of two formulations of the investigational COVID-19 treatment remdesivir. Recommendations to guide safe practice include use of standard order sets and dosing clarifications.

'I'm smiling under here': Masks, plexiglass and questions the norm as hospitals lure patients back in COVID-19 era.

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Weintraub K. USA Today. 2020;June 3.

COVID-19 transmission concerns have kept some patients from seeking needed medical care. This story highlights strategies hospitals are employing to demonstrate their commitment to keeping cancer patients safe, such as physical distancing guidance and plexiglass partitions.

Mask shortage straps pharmacists who need them to keep medicines pure.

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Jewett C, Lupkin S. National Public Radio. 2020.

Disruptions in medication compounding activities can impact safety. This news story discussed the shortage of protective masks for pharmacists and the potential unintended consequences that could result in medication-related harms. Targeted concerns include reducing sterile space for medication compounding and moving preparation to the patient bedside, which could expose the process to distractions.

Errors associated with oxytocin use: a multi-organization analysis by ISMP and ISMP Canada.

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ISMP Medication Safety Alert! Acute care edition. February 13, 2020;25(3):1-6.

Errors in IV medication use can result in serious adverse health consequences. This article shares an analysis of approximately 200 oxytocin incident reports. Five areas of concern identified include prescribing, look alike/sound alike packaging, preparation, administration and communication problems. Patient engagement, bar coding use and verbal order reduction are highlighted amongst the listed improvement strategies.

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