The PSNet Collection

Clinician distress and inappropriate antibiotic prescribing for acute respiratory tract infections: a retrospective cohort study.

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Brady KJS, Barlam TF, Trockel MT, et al. Jt Comm J Qual Patient Saf. 2022;48:287-297.

Inappropriate prescribing of antibiotics to treat viral illnesses is an ongoing patient safety threat. This study examined the association between clinician depression, anxiety, and burnout and inappropriate prescribing of antibiotics for acute respiratory tract infections (RTIs) in outpatient care. Depression and anxiety, but not burnout, were associated with increased adjusted odds of inappropriate prescribing for RTIs.

Clinic design for safety during the pandemic: safety or teamwork, can we only pick one?

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Lim L, Zimring CM, DuBose JR, et al. HERD. 2022;15:28-41.

Social distancing policies implemented during the COVID-19 pandemic challenged healthcare system leaders and providers to balance infection prevention strategies and providing collaborative, team-based patient care. In this article, four primary care clinics made changes to the clinic design, operational protocols, and usage of spaces. Negative impacts of these changes, such as fewer opportunities for collaboration, communication, and coordination, were observed.

Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety.

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ISMP Medication Safety Alert! Acute care edition. April 7, 2022; 27(2):1-6.

The Institute for Safe Medication Practices (ISMP) highlights the negative impacts the recent criminal conviction of a nurse could have for patient safety, including fear of reporting errors and clinicians leaving the profession.

How to scale up quality and safety program with the home care accreditation.

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Brunelli L, Cristofori V, Battistella C, et al. Int J Integr Care. 2022;22:19.

Accreditation programs are intended to improve patient safety and quality of care. Researchers in Italy aimed to develop and validate an accreditation tool for home care. The tool, validated by 21 experts, is divided into six domains: 1) Organization and governance; 2) Patient safety and risk management; 3) Professionals’ knowledge, skills, and competencies; 4) Information and communication; 5) Care integration, and 6) Improvement and innovation.

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

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April 7, 2022

Mobile health apps are becoming increasingly popular for patients and clinicians. This innovative study implemented a pharmacist-led mobile health based intervention to improve medication safety of patients following kidney transplant.

Annual Perspective: Topics in Medication Safety

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March 31, 2022

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

Annual Perspective: Psychological Safety of Healthcare Staff

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March 31, 2022

A psychologically safe environment for healthcare teams is desirable for optimal team performance, team member well-being, and favorable patient safety outcomes. This piece explores facilitators of and barriers to psychological safety across healthcare settings. Future research directions examining psychological safety in healthcare are discussed.

Preventing delayed and missed care by applying artificial intelligence to trigger radiology imaging follow-up.

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Domingo J, Galal G, Huang J. NEJM Catalyst. 2022;3.

Failure to follow up on abnormal diagnostic test results can cause delays in patients receiving appropriate care. This hospital used an artificial intelligence natural language processing system to identify radiology reports requiring follow-up. The system triggered automated notifications to the patient and ordering provider, and tracked follow-ups to completion. System development, deployment and next steps are detailed.

Leveraging a safety event management system to improve organizational learning and safety culture.

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Dawson R, Saulnier T, Campbell A, et al. Hosp Pediatr. 2022;12:407-417.

Voluntary error reporting remains underutilized in many clinical settings despite its importance for organizational learning and improved patient safety. This pediatric health system implemented a new safety event management system (SEMS) aimed at increased usability, de-centralized event follow-up, and closed-loop communication. The new SEMS resulted in more event reporting and less staff time spent on each report.

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.

Remote patient monitoring during COVID-19: an unexpected patient safety benefit.

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Pronovost PJ, Cole MD, Hughes RM. JAMA. 2022;327:1125-1126.

The COVID pandemic has increased demand and acceptance of remote care modalities. This commentary suggests that home monitoring is a promising telehealth approach and that its application could improve value while enhancing safety for hospital-at-home and other levels of home-based care patients.

Human Factors In Healthcare.

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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.

Physician liability in the age of data reliance and errors.

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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.

Caring for Those Who Care: Guide for the Development and Implementation of Occupational Health and Safety Programmes for Health Workers.

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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.

When no news is bad news: improving diagnostic testing communication through patient engagement.

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Zomerlei T, Carraher A, Chao A, et al. J Patient Saf Risk Manage. 2021;26:221-224.

Failure to communicate abnormal test results to patients can lead to significant health complications and medical malpractice claims. This study aimed to increase patient engagement in asking their provider about previously obtained diagnostic test results. Reminders to follow up with their provider about test results were sent to the patient via the after-visit summary and patient portal. Patients receiving reminders were up to 20 times more likely to ask their providers about their test results, compared to patients who did not receive reminders.

Eliminating explicit and implicit biases in health care: evidence and research needs.

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Vela MB, Erondu AI, Smith NA, et al. Annu Rev Public Health. 2022;43:477-501.

Implicit biases among healthcare providers can contribute to poor decision-making and impede safe, effective care. This systematic review assessed the efficacy of interventions designed to reduce explicit and implicit biases among healthcare providers and students. The researchers found that many interventions can increase awareness of implicit biases among participants, but no intervention achieved sustained reduction of implicit biases. The authors propose a conceptual model illustrating interactions between structural determinants (e.g., social determinants of health, language concordance, biased learning environments) and provider implicit bias.

Patient safety when receiving telephone advice in primary care - a Swedish qualitative interview study.

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Berntsson K, Eliasson M, Beckman L. BMC Nurs. 2022;21:24.

Safe and accurate telephone triage is of critical importance, particularly during the COVID-19 pandemic. This Swedish study evaluated district nurses’ experiences and perceptions of patient safety at a national nurse advice triage call center. Interviews with nurses resulted in an overall theme of “being able to make the right decision” based on the categories of “communication” and “assessment.”

Association of adverse events in opioid addiction treatment with quality measure for continuity of pharmacotherapy.

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Liu Y, Becker A, Mattke S. J Healthc Qual. 2022;44:e38-e43.

Medication-assisted treatment (MAT) is increasingly used to treat opioid use disorder (OUD). This study found that providers or practices with higher quality measure scores of MAT continuity (percentage of patients with OUD who had at least 180 days of continuous treatment) had a lower risk of opioid-related adverse events among their patients.

Evaluating incident learning systems and safety culture in two radiation oncology departments.

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Adamson L, Beldham‐Collins R, Sykes J, et al. J Med Radiat Sci. 2022;69:208-217.

Reporting of near misses and adverse events can provide a foundation for learning from error. This quality improvement project surveyed radiation oncology staff in two local health districts to assess understanding and use of incident learning systems, barriers to reporting or needs for process change, and perception of departmental safety culture. System processes (e.g., takes too long) were identified as barriers to reporting more frequently than safety culture (e.g., fear of negative action towards self or others).

AMA Prior Authorization (PA) Physician Survey.

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Chicago, IL: American Medical Association; February 2022.

Insurance policies can have consequences that reduce the safety of medical care. This latest version of the study surveyed 1000 physicians in 2021 to find that prior authorization requirements contributed to patient harm or potentially preventable hospitalization 34 percent of the time.

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