Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
PSNet Original Content
1 - 20 of 29
Plunkett A, Plunkett E. Paediatr Anaesth. 2022;Epub Jun 18.
Safety-I focuses on identifying factors that contribute to incidents or errors. Safety-II seeks to understand and learn from the many cases where things go right, including ordinary events, and emphasizes adjustments and adaptations to achieve safe outcomes. This commentary describes Safety-II and complementary positive strategies of patient safety, such as exnovation, appreciative inquiry, learning from excellence, and positive deviance.
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.
Serou N, Sahota LM, Husband AK, et al. Int J Qual Health Care. 2021;33:mzab046.
High reliability organizations consistently examine and learn from failures. This systematic review identified several effective learning tools that can be adapted and used by multidisciplinary health care teams following a patient safety incident, including debriefing, simulation, crew resource management, and reporting systems. The authors concluded that these tools have a positive impact on learning if used soon after the incident but further research about successful implementation is needed.
Kaldjian LC. Patient Educ Couns. 2021;104:989-993.
Disclosure of and communication about errors and adverse events is increasingly encouraged in health care. This position paper discusses the key elements for effective communication about medical errors with patients and families and the importance of disclosure education in medical training, including the development of nonverbal skills.
De Brún A, Anjara S, Cunningham U, et al. Int J Environ Res Public Health. 2020;17:8673.
Leadership has an important role in promoting a culture of safety and enabling necessary changes to enhance patient safety. This article summarizes the design, pilot testing, and refinement of the Collective Leadership for Safety Culture (Co-Lead) program, which offers a systematic approach to developing collective leadership behaviors to promote effective teamwork and enhance safety culture.
Gallagher TH, Boothman RC, Schweitzer L, et al. BMJ Qual Saf. 2020;29:875-878.
Communication-and-resolution programs (CRP) emphasize early disclosure of adverse events and proactive approaches to resolving patient safety issues. This editorial discusses strategies for successful implementation of CRPs highlighted in prior research, including its prioritization by institutional leadership, investment in tools and resources necessary for implementation, and the use of metrics to track CRP functioning. 

Auraaen A, Saar K, Klazinga N for the Organisation for Economic Co-operation and Development. OECD Publishing, Paris, France; 2020. OECD Health Working Papers, No. 120.

Policies, laws, and guidelines aid organizations to develop, prioritize and achieve patient safety goals. This report examined a 25-country analysis of patient safety governance efforts and found that learning and non-punitive approaches are strategies being progressively implemented worldwide.
Dubé MM, Kaba A, Cronin T, et al. Adv Simul (Lond). 2020;5:22.
This article describes the planning and implementation of a multi-site, multidisciplinary simulation program to provide critical just-in-time COVID-19 education in one Canadian province. The authors discuss the unique features and advantages of a centralized simulation response and key themes of the simulation program.

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.

Boston, MA: Institute for Healthcare Improvement: September 2020.  

This National Action Plan developed by the National Steering Committee for Patient Safety – a group of 27 national organizations convened by the Institute for Healthcare Improvement – provides direction for health care leaders and organizations to implement and adapt effective tactics and supportive actions to establish the recommendations laid out in the plan. Its areas of focus include culture, leadership, and governance, patient and family engagement, workforce safety and learning systems.  
J Patient Saf. 2020;16:s1-s56.
The patient safety evidence base has been growing exponentially for two decades with noted expansion into the non-acute care environment. This special issue highlights eight articles illustrating the range of practices examined in the AHRQ Making Healthcare Safer III report, including rapid response teams and failure to rescue, deprescribing practices and opioid stewardship.   
Yong E. The Atlantic. 2020;September.
This article takes a holistic view of the multiple preventable failures of the U.S. in managing the COVID-19 pandemic, raising several patient safety issues from the metasystems perspective. The piece highlights systemic problems such as lack of transparency, investment in public health and learning from experience.
Singh H, Sittig DF, Gandhi TK. BMJ Qual Saf. 2021;30:141-145.
This Viewpoint presents examples of short-term positive effects resulting from early COVID-19-related patient safety efforts, including a focus on (1) high-reliability organizations and safety culture focusing on transparency, collaboration, reporting, and speaking up, (2) prioritizing workplace safety, and (3) removing barriers to using health IT (e.g., EHRs, telemedicine) to improve safety and how to create some permanent/sustainable methods to prevent harm.
Kim S, Appelbaum NP, Baker N, et al. J Healthc Qual. 2020;42:249-263.
This review summarizes studies of training programs targeting healthcare professionals’ speaking up skills. The authors found that most training programs were limited to a one-time training delivered to a single profession (i.e., limited to doctors or nurses).  The majority of programs addressed legitimate power (i.e., social norms such as titles) but few addressed other types of power (e.g., reward or coercive power, personal resources) or the non-verbal (i.e., emotional) skills required in speaking-up behaviors.  
Giardina TD, Royse KE, Khanna A, et al. Jt Comm J Qual Patient Saf. 2020;46:282-290.
This study analyzed self-reported adverse events captured on a national online questionnaire to determine the association between patient-reported contributory factors and patient-reported physical, emotional or financial harm. Contributory factors identified in the analysis focused on issues with health care personnel communication, fatigue, or response (e.g., doctor was slow to arrive, nurse was slow to respond to call button). These patient-reported contributory factors increased the likelihood of reporting any type of harm.
Houghton C, Meskell P, Delaney H, et al. Cochrane Database Syst Rev. 2020;4:CD013582.
To support the needs of healthcare workers during the COVID-19 pandemic, this rapid evidence review of qualitative research studies sought to identify barriers and facilitators to healthcare workers adherence to infection prevention and control guidelines for respiratory infectious diseases. The authors included 20 studies in their analysis; these studies explored the views and experiences of nurses, doctors and other healthcare workers working in hospitals, primary care, and community care settings dealing with infectious diseases such as SARS, H1N1, MERS, TB, or seasonal influenza. Identified barriers included local guidelines that were lengthy, ambiguous or not reflective of national or international continuously changing guidelines, lack of support from management to adhere to guidelines, and lack of high-quality personal protective equipment (PPE). Facilitators to guideline adherence included clear communication and training about the infection and use of PPE, sufficient space to isolate patients, workplace safety culture, and perceived value of adhering to infection prevention and control guidelines.
Leistikow I, Bal RA. BMJ Qual Saf. 2020;29:869–872.
This article discusses how resilience and learning from things that go right (i.e., Safety-II) can influence interactions between healthcare providers and external regulatory systems. The authors present the five core concepts of Safety-II (definition of safety, safety management principles, human factors, accident investigation, and risk assessment) and depict their impact on accountability between healthcare providers and regulators.

People’s Pharmacy.  Show 1209. April 28, 2020.

Accidental harm to patients is a persistent challenge in health care. This interview features Dr. Danielle Ofri who provides an overview of error in medicine. She draws from both general and COVID-19 pandemic care experiences to illustrate the difficulties involved in measuring, understanding and improving patient safety.