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Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.

Occupational Safety and Health AdministrationMarch 2, 2022.

The impact of nursing home inspections to ensure the quality and safety of the service environment is lacking. Weaknesses in the process became more explicit as poor long-term care infection control was determined to be a contributor to the early spread of COVID amongst nursing home residents. This announcement outlines a targeted inspection initiative to assess whether organizations previously sited have made progress toward improving workforce safety.

Keebler JR, Salas E, Rosen MA, et al. eds. Hum Factors. 2022;64(1):5-258.

Human factors concepts are central to improvement in high-risk industries and efforts are emerging to enfold them into health care organizations to improve safety. This special issue explores themes that underscore successful application of human factors practices into healthcare: culture change toward high reliability, team improvement, technology integration, and measures development.

Montesantos L. Ann Health Law Life Sci. 2022;31(Spring):179-215.

Health information technologies (HIT) and advanced learning systems, if poorly designed, used, maintained, integrated, or accessed, harbor the potential for failure across the systems they support. This legal discussion argues for federal standards to establish levels of accountability for physicians who use HIT systems and assign liability, should use result in patient harm.

Geneva, Switzerland: World Health Organization and International Labour Organization; 2022. ISBN 9789240040779.

Workforce well-being emerged as a key component of patient safety during the COVID-19 crisis. This report supplies international perspectives for informing the establishment of national regulations and organization-based programs to strengthen efforts aiming to develop health industry workforce health and safety strategies.
Residents living in nursing homes or residential care facilities use common dining and activity spaces and may share rooms, which increases the risk for transmission of COVID-19 infection. This document describes key patient safety challenges facing older adults living in these settings, who are particularly vulnerable to the effects of the virus, and identifies federal guidelines and resources related to COVID-19 prevention and mitigation in long-term care. As of April 13, 2020, the Associated

Washington, DC: United States Government Accountability Office; November 30, 2021. Publication GAO-22-105142.

Patient complaints have the potential to be used for care improvement as they surface problems in health facilities. This report examined complaint response processes in Veterans Affairs nursing homes and found them lacking. Five recommendations submitted to drive improvement underscore the value of adherence to policy and the transfer of complaint experiences to leadership.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.
Weenink J-W, Wallenburg I, Leistikow I, et al. BMJ Qual Saf. 2021;30:804-811.
This qualitative study explored the impact of published inspection frameworks on quality and safety in nursing home care, dental care, and hospital care. Respondents noted the importance of the inspection framework design, the role of existing institutional frameworks, and how the frameworks can influence quality improvement across various organizational levels.
Alexander GL, Madsen RW. J Patient Saf. 2021;17:e483-e489.
Information technology (IT) is prevalent across healthcare settings. This study used publicly available nursing home data and a survey on IT sophistication to identify the relationship between nursing home health deficiencies and IT sophistication. Results indicate health deficiencies decreased as IT sophistication increased, suggesting investment in IT could lead to further patient safety benefits in nursing homes.
Serre N, Espin S, Indar A, et al. J Nurs Care Qual. 2022;37:188-194.
Safety concerns are common in long-term care (LTC) facilities. This qualitative study of LTC nurses explored nurses’ experiences managing patient safety incidents (PSI). Three categories were identified: commitment to resident safety, workplace culture, and emotional reaction. Barriers and facilitators were also discussed.
Adams KT, Pruitt Z, Kazi S, et al. J Patient Saf. 2021;17:e988-e994.
It is important to consider unintended consequences when implementing new tools, such as health information technology (HIT). This study reviewed 2,700 patient safety event reports to identify the type of medication error, the stage in the process in which the error occurred, and how HIT usability issues contributed to the errors. Errors in dosing were the most frequent type, and occurred during ordering or reviewing. Most errors described usability issues which should be considered and addressed to improve medication safety.
Sloane PD, Yearby R, Konetzka RT, et al. J Am Med Dir Assoc. 2021;22:886-892.
Racial bias and racism are increasingly seen as a critical patient safety issue. In this article, the authors outline the components of systemic racism (structural/institutional, cultural, and interpersonal), how they manifest and affect the long-term care system, and the detrimental impact of systemic racism on Blacks during the COVID-19 pandemic.
Kruse CS, Mileski M, Syal R, et al. Technol Health Care. 2020;29:1-14.
Health information technology (HIT) can promote patient safety in many settings. This systematic review found that HIT, such as computerized provider order entry (CPOE) systems, can improve safe prescribing practices in long-term care settings, including improved documentation and clinical processes, and fewer medication errors.
Gandhi A, Yu H, Grabowski DC. Health Aff (Millwood). 2021;40:384-391.
Prior research has found that high nursing staff turnover is associated with lower patient safety culture. Starting in July 2016, the Centers for Medicare & Medicaid Services (CMS) began collecting daily staffing data for US nursing homes and found that nurse turnover rates were correlated with facility location, for-profit status, Medicaid patient census, and star ratings. This information can be leveraged by policymakers, payers, and healthcare consumers and may incentive efforts to reduce nursing staff turnover.
Dellinger JK, Pitzer S, Schaffler-Schaden D, et al. BMC Geriatr. 2020;20:506.
Polypharmacy in older adults is common and may increase risk of medication-related adverse events. This study found that an intervention combining educational training, tailored health information technology, and a therapy check process improved medication appropriateness in nursing home residents.  
Gleason KT, Harkless G, Stanley J, et al. Nurs Outlook. 2021;69:362-369.
To reduce diagnostic errors, the National Academy of Medicine (NAM) recommends increasing nursing engagement in the diagnostic process. This article reviews the current state of diagnostic education in nursing training and suggests inter-professional individual and team-based competencies to improve diagnostic safety.