The PSNet Collection

Establishing psychological safety in clinical supervision: multi-professional perspectives.

Save to Library

Lee EH, Pitts S, Pignataro S, et al. Clin Teach. 2022;19:71-78.

The inherent power imbalance between supervisors and new clinicians may inhibit new clinicians from asking questions or reporting mistakes. This lack of psychological safety can result in patient harm and restrict learning. This article provides strategies for healthcare educators and leaders to model and guide a safer organization. Three phases of the supervisor-learner relationship, along with suggested prompts, are provided.

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

Save to Library

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.

The Color of Care.

Save to Library

Chicago, IL: Harpo Productions, Smithsonian Channel: May 2022.

The COVID-19 pandemic revealed the impact of racial disparities and inequities on patient safety for patients of color. This film shares stories of families whose care was unsafe. The cases discussed highlight how missed and dismissed COVID symptoms and inattention to patient and family concerns due to bias reduces patient safety.

Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS.

Save to Library

London UK: Patient Safety Learning: 2022.

Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financially. This report examines large system failures in the UK National Health Service to suggest actions that support learning and improvement. The publication highlights how public investigations, government reports, legal actions, and patient complaints can provide information to support the systems approach required to arrive at safe care.

Patient Safety Authority Annual Reports.

Save to Library

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.

The Media’s Role in Patient Safety

Save to Library

April 27, 2022

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

Healthcare Simulation Week.

Save to Library

Society for Simulation in Healthcare.

Simulation provides a safe space to observe behaviors and generate constructive feedback to enhance individual and team performance. This website provides promotional materials for an annual campaign to raise awareness of professionals that use simulation to develop teamwork, communication, and crisis management skills in health care. The 2022 observance will be held September 12-16.

Effects of tall man lettering on the visual behaviour of critical care nurses while identifying syringe drug labels: a randomised in situ simulation.

Save to Library

Lohmeyer Q, Schiess C, Wendel Garcia PD, et al. BMJ Qual Saf. 2022;Epub Mar 8.

Tall Man lettering (TML) is a recommended strategy to reduce look-alike or sound-alike medication errors. This simulation study used eye tracking to investigate how of ‘tall man lettering’ impacts medication administration tasks. The researchers found that TML of prelabeled syringes led to a significant decrease in misidentified syringes and improved visual attention.

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

Save to Library

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

Save to Library

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

Save to Library

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.

World Patient Safety Day.

Save to Library

World Health Organization. September 17, 2022.

Patients, families, and providers around the world are affected by medical error. This annual event and associated materials seek to raise awareness, motivate collaboration, and stimulate innovative work targeting a distinct patient safety theme. The 2022 theme is “Medication safety” with the slogan “Medication without Harm".

Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes

Save to Library

February 24, 2022

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

Proposed 2022 CDC clinical practice guideline for prescribing opioids. A notice by the Centers for Disease Control and Prevention.

Save to Library

Fed Register. February 10, 2022;87: 7838-7840.

The 2016 Centers for Disease Control opioid guidelines have raised concerns as to their potential to contribute to patient harm. This announcement calls for comments from the field to inform and update current policy in response to safety issues that emerged as unintended consequences of the 2016 recommendation. Comments are due to be submitted by April 11, 2022.

Achieving Excellence in Cancer Diagnosis: Proceedings of a Workshop—in Brief.

Save to Library

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022.

Diagnostic errors remain an ongoing challenge in many medical specialties, including oncology. This workshop reviewed the evidence base examining challenges in cancer diagnosis, discussed suggestions for improvement in the field, and looked toward a safer future for cancer patients.

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

Save to Library

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.

AMA Prior Authorization (PA) Physician Survey.

Save to Library

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.

Medication errors in overweight and obese pediatric patients: a systematic review.

Save to Library

Procaccini D, Kim JM, Lobner K, et al. Jt Comm J Qual Patient Saf. 2022;48:154-164.

Weight-based medication dosing is a common source of medication errors in children. This systematic review identified limited evidence that overweight and obese children maybe be at increased risk of weight-based medication dosing errors, but the authors note that the clinical significance is unknown.

Diagnostic reasoning in cardiovascular medicine.

Save to Library

Brush JE, Sherbino J, Norman GR. BMJ. 2022;376:e064389.

Misdiagnosis of heart failure can lead to serious patient harm. This article reviews the cognitive psychology of diagnostic reasoning in cardiology. Strategies for educators, students, and researchers to reduce cardiovascular misdiagnosis are presented.

"Some version, most of the time": the surgical safety checklist, patient safety, and the everyday experience of practice variation.

Save to Library

Hammond Mobilio M, Paradis E, Moulton C-A. Am J Surg. 2022;223:1105-1111.

Surgical safety checklists (SSC) have been adopted around the world, but reported compliance rates and use in practice vary widely. This study in one Canadian hospital showed the SSC was used in 82% of Briefings, 76% of Time-Outs, and 22% of Debriefings. Gaps between policy and practice were identified and implications for policy makers, administrators, frontline clinicians, and researchers are discussed.

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users