The PSNet Collection

At US hospitals, a drug mix-up is just a few keystrokes away.

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Kelman B. Kaiser Health News. April 29, 2022.

Technological solutions harbor unique risks that can result in patient harm. This article shares a response to reports of automated dispensing cabinet (ADC) menu selection limitations that contribute to mistakes. The piece suggests the implementation of a 5-letter search requirement prior to removing a medication from an ADC. It provides an update on industry response to this forcing function recommendation.

The Media’s Role in Patient Safety

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April 27, 2022

This piece discusses the role that media plays in affecting patient safety.

Will prosecuting medical errors lead to a culture of silence?

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Fiore K. MedPage Today. March 28, 2022.

Experts are concerned that convictions for medical error have the potential to limit dialogue on the front line about medical mistakes. This article summarizes discussions regarding the verdict to convict a nurse due to a workaround that resulted in a medication error and patient death.

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.

Maternity Pre-arrival Instructions by 999 Call Handlers.

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Farnborough, UK: Healthcare Safety Investigation Branch; February 17, 2022.

Pre-hospital emergency care can be vulnerable to timing, information, and task failures that compromise safety. This investigation explores how computerized decision support system access played a roles in an emergency call-center program incident where erroneous information was transmitted to a pregnant patient that contributed to infant harm.

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.

Confronting Racism in Health Care: Moving from Proclamations to New Practices.

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Hostetter M, Klein S. New York, NY: Commonwealth Fund; October 18, 2021

Structural racism affects the safety and equity of care delivery. This report summarizes organizational efforts to reduce the impact of systemic racism on patient care, hiring practices, and policy implementation to ensure transparent, equitable and patient-centered care is reliably available to all.

Lessons Learned? Building a Culture of Patient Safety Within the Veterans Health Administration.

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US House of Representatives Committee on Veterans' Affairs Subcommittee on Health. 117th Cong. 1^st Sess (2021).

The Veterans Health Administration is a large complex system that faces various challenges to safe care provision. At this hearing, government administrators testified on current gaps that detract from safe care in the Veteran’s health system. The experts discussed several high-profile misconduct and systemic failure incidents, suggested that the culture and leadership within the system overall enables latency of issues, and outlined actions being taken to address weaknesses.

Agency information collection activities: National Healthcare Safety Network (NHSN); comment request.

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Zirger JM, Centers for Disease Control and Prevention. Fed Register. September 27, 2021;86:53309-53312.

Tracking healthcare-associated infection (HAI) data aids in national, regional, and organizational design of HAI improvement efforts. This notice calls for public comment on the continuation of the National Healthcare Safety Network HAI information collection process. The comment period closes November 26, 2021.

Agency information collection activities: Ambulatory Surgery Center Survey on Patient Safety Culture Database; comment request.

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Agency for Healthcare Quality and Research. Fed Register. August 31, 2021;86:48703-48705.

This announcement calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Ambulatory Surgery Center Survey on Patient Safety Culture Database data collection process. The comment period is closed.

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.

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Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.

Organizational assessments often provide insights that address overarching quality and safety challenges. This extensive inspection report shares findings from inspections of 36 Veterans Health Administration care facilities. Recommendations drawn from the analysis call for improvements in suicide death review, root cause analysis result application, and safety committee action item implementation.

'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.

Federal speech rulings may embolden health care workers to call out safety issues.

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Meyer H. Kaiser Health News. July 9, 2021.

Whistleblower protections are a key component to raising awareness of safety issues in work environments. This news story examines how US federal law has opened the door for the media as a platform for employees to highlight conditions that reduce staff and patient safety in health care environments.

Medical malpractice claims by members of the uniformed services.

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Department of Defense Office of General Counsel. 32 CFR Part 45. Fed Register. 86(115); June 17, 2021:32194-32215.

Organizations with safety cultures facilitate the ability for an injured patient to seek an effective response to untoward incidents. This United States rule outlines the standards that enable members of the armed forces to file claims should they be harmed while in the military health care system.

Using Twitter to assess patient takes on patient experience.

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Heath S. Patient Engagement HIT. October 29, 2020.

Twitter is evolving as a useful data source for patient safety. This news story discusses an examination of public use of a patient-complaint hashtag that recorded patient experiences of misdiagnosis, disrespect and miscommunication that contributed to poor relations with physicians, medical errors, and harm.

Investigation into the Role of Clinical Pharmacy Services in Helping to Identify and Reduce High-risk Prescribing Errors in Hospital.

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Farnborough, UK: Healthcare Safety Investigation Branch; September 24, 2020.

Unit-based pharmacy services help to mitigate and catch medication errors. This report highlights a case of a medication error death and describes how embedding clinical pharmacy services could have prevented this incident. The report provides system level recommendations to enhance this service including defining the role of clinical pharmacy teams and prioritizing the tactic as an important improvement strategy.

Making Complaints Count: Supporting Complaints Handling in the NHS and UK Government Departments.

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London, UK: The Parliamentary and Health Service Ombudsman; July 15, 2020. ISBN 9781528620666.

Patient and family complaints can provide insights into system weaknesses if managed effectively. This report examined complaint handling at the United Kingdom National Health Service. The analysis found that lack of training, consistency and learning orientation reduced the effectiveness of the effort.

Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee.

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Washington, DC: Department of Veterans Affairs, Office of Inspector General; September 3, 2020. Report No 19-09493-249.

Discontinuities in mental health care are a patient safety concern. This report analyzes how documentation gaps, medication reconciliation problems, and poor care coordination contributed to the suicide of a patient who presented at an emergency room, was screened there, and referred to a clinic for further care that was not completed.

Patient Safety

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Organisation for Economic Co-operation and Development.

Organizations worldwide are focusing efforts on reducing the conditions that contribute to medical error. This website provides a collection of reports and other resources that cover activities and concerns of the 37 member countries active in the organization to address universal challenges to patient safety.

Amid COVID-19, discipline against bad doctors plummets; more medical errors may slip through cracks.

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O'Donnell J. USA Today. September 8, 2020

Management and clinical functions to ensure patient safety have been disrupted during the COVID-19 pandemic. This article discusses how tracking and submitting of reports of questionable medical care have been reduced due to redirection of efforts of all to managing pandemic related activities.

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