The PSNet Collection

As a nurse faces prison for a deadly error, her colleagues worry: could I be next?

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Kelman B. Kaiser Health News. March 22, 2022

Criminalization of medical mistakes typifies the blame-focused approach patient safety leaders have worked to reduce in health care. This article covers a high-profile case of medication error involving an automated dispensing system that is ubiquitous in health care.

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.

A widow’s mission to change NC dental sedation rules.

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Blythe A. NC Health News. March 10, 2022

Patient harm in dentistry is receiving increased attention and scrutiny. This story covers a medication incident and the lack of safety support that contributed to the death of a patient receiving oral surgery. It discusses the response of the patient’s family and their work to change regulations for dental sedation.

Survey suggests disrespectful behaviors persist in healthcare: practitioners speak up (yet again) – Parts I and II.

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ISMP Medication Safety Alert! Acute care edition. February 24, 2022; 27(4):1-5; March 10, 2022; 27(5):1-5.

Disrespect for co-workers, peers, and patients degrades safety in the care environment. Part I of this article series summarizes results from a 2021 survey as the latest installment of a long-standing examination of the prevalence of disrespectful behaviors. The results found that poor behaviors are common, a wide array of unprofessional behaviors are encountered in the workplace, and how they affect safety. Part II shares strategies to decrease the presence and impact of disrespectful behaviors in health care which include creation of confidential reporting systems and support structures.

She was headed to a locked psych ward. Then an ER doctor made a startling discovery.

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Boodman SG. Washington Post. February 12, 2022.

Misdiagnosis over a long period of time can be acerbated by stigma and cognitive bias. This news story illustrates the problem of omissions due to potential stigma associated with patient mental health issues that contributed to a missed diagnosis. The author discusses how clinician experience led to flagging of a different testing approach to reveal a diagnosis that, once addressed, improved the patient's health.

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Medication/Drug Errors

‘They treat me like I’m old and stupid’: seniors decry health providers’ age bias.

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Graham J. Kaiser Health News. October 20, 2021.

Implicit biases permeate decision making and can impede safe and effective diagnosis and treatment. This story examines how ageism results in undertreatment, mistakes, poor communication and care rationing.

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.

A crisis within a crisis.

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Ellis NT, Broaddus A. CNN. August 25, 2021.

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.

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Maternal Safety

Doctors were sure they had Covid-19. The reality was worse.

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Browne G. Wired UK. April 23 2021

Diagnosis can be challenged by cognitive bias, fatigue, and lack of knowledge. This article discusses how availability biases, uncertainty, and other decision-making missteps effected diagnosis of non-COVID disease early in the pandemic.

Start the year off right by preventing these top 10 medication errors and hazards from 2020.

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ISMP Medication Safety Alert! Acute care edition. January 27, 2021;26(2).

Medication safety is challenged by both persistent problems and emerging situations. This article summarizes reports of errors submitted voluntarily to the Institute for Safe Medication Practices (ISMP) in 2020. The set list includes both pandemic-related hazards and common problems such as use of abbreviations and opioid-naïve patient prescribing.

Not ‘just depression.’ She seemed trapped in a downward mental health spiral. The real cause was a profound shock.

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Boodman SG. Washington Post. January 23, 2021.

Misdiagnosis can perpetuate over a long period and delay a correct course of treatment. This news feature shares an example of depression misdiagnosis that masked the true problem of a neurological tumor manifesting in what was seen and treated as a psychological condition.

Learning from errors with the new COVID-19 vaccines.

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ISMP Medication Safety Alert! Acute Care Edition. January 14, 2021;26(1);1-5.

Learning from error rests on transparency efforts buttressed by frontline reports. This article examined reports of COVID-19 vaccine errors to highlight common risks that are likely to be present in a variety of settings and share recommendations to minimize their negative impact, including storage methods and vaccination staff education.

A night in the hospital, from both ends of the stethoscope.

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Ofri D. New York Times. January 5, 2021.

Physicians have unique perspectives when exposed to health care delivery problems as patients themselves or as caregivers. This news story shares the author’s frustrations with the system of care observed during an overnight visit at the bedside of her daughter awaiting an emergency appendectomy. Her experience underscored the value of patients and families engaging in the safety of actions clinicians take when providing care.

Doctors' unconscious bias affects quality of health care services, research shows.

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Dembosky A. All Things Considered. National Public Radio. October 15, 2020.

Physician implicit bias is gaining attention as a patient safety concern. This piece shares a story of ineffective care delivery to a patient with COVID-19 as context for the discussion. Hospital tactics to address the problem such as training and use of patient survey data to motivate individual action are reviewed.

A doctor gave me an inept diagnosis for a neurological problem. I should know: I’m a neurologist.

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Horowitz SH. Washington Post. October 4, 2020.

The harm of misdiagnosis can be extended by lack of clinician recognition and acceptance of the error when a patient raises concerns. This news story shares the experience of a physician-patient whose recognition of a diagnostic mistake was initially dismissed. The author defines the repeated lack of organizational willingness to resolve the situation as a normalized deviance in health care.

‘You’re going to release him when he was hurting himself?’

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Dahlberg B. Kaiser Health News. September 29, 2020.

This story discusses failures related emergency psychiatric assessment, including premature discharge, implicit bias, patient management discontinuity and inappropriate physical restraint that contributed to the death of a patient at risk for suicide.

Without an 'ounce of empathy': their stories show the dangers of being Black and pregnant.

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Ramaswamy SV. Rockland/Westchester Journal News. September 9, 2020.

Implicit and explicit biases affect many facets of the health care delivery system. This story shares African-American patient experiences with bias that reduced the safety of maternity care.

Two pandemics, same story: the potentially dangerous overuse of antibiotics and 'the road to medical hell'.

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Fauber J, Chen D. USA Today. August 31, 2020.

Antibiotic overuse is a long-standing safety concern due to the potential global public health impact of the practice in supporting drug-resistant bacteria. This news article discusses the overprescribing of antibiotics in context of viral disease pandemics.

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