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Olazo K, Wang K, Sierra M, et al. Jt Comm J Qual Patient Saf. 2022;Epub Jun 22.
Patients and families prefer to be told if they experience a medical error. Given that marginalized patients experience medical errors at higher rates, it is important to understand their unique perspectives and preferences towards error disclosure. This systematic review identified 6 studies focused on error disclosure in one of three marginalized populations (older adults, low education attainment, racial and/or ethnic minority).
Harrison R, Johnson J, McMullan RD, et al. J Patient Saf. 2022;Epub May 25.
Providers who are involved in a medial error may experience a range of negative emotions and utilize a variety of coping mechanisms following the error. The authors update their 2010 systematic review on medical professionals’ coping with medical error and apply their Recovery from Situations of Error Theory (ReSET) model. The ReSET model provides a basis to develop and evaluate interventions to reduce feelings of distress and increase providers’ coping skills.
Montgomery A, Lainidi O, Johnson J, et al. Health Care Manage Rev. 2022;Epub Jun 16.
When faced with a patient safety concern, staff need to decide whether to speak up or remain silent. Leaders play a crucial role in addressing contextual factors behind employees’ decisions to remain silent. This article offers support for leaders to create a culture of psychological safety and encourage speaking up behaviors.
Maher V, Cwiek M. Hosp Top. 2022;Epub Jul 20.
Fear of criminal liability may inhibit clinicians from reporting medical errors, thereby reducing opportunities for learning. This commentary discusses recent legal actions brought against clinicians, including Tennessee nurse RaDonda Vaught, and the negative impact such actions may have on the longstanding disclosure movement.
Institute for Healthcare Improvement. September 14--November 22, 2022.
Burnout among health care workers negatively affects system improvement. This webinar series will highlight strategies to establish a healthy work environment that strengthens teamwork, staff engagement, and resilience. Instructors include Dr. Donald Berwick and Derek Feeley.
Yeh JC, Chae SG, Kennedy PJ, et al. J Pain Symptom Manage. 2022;Epub May 25.
Potentially inappropriate opioid infusion use can result in adverse patient outcomes. This single-site retrospective study found that potentially inappropriate opioid infusions are prevalent (44% of patients receiving opioid infusions during end-of-life care) and were associated with high rates of patient and staff distress.
Velasco RAF, Slusser K, Coats H. J Adv Nurs. 2022;Epub Jun 10.
Transgender and gender-diverse may experience poor quality of healthcare due to stigma and discrimination. This systematic review of qualitative studies found that stigma experienced among transgender and gender-diverse patients occurs at the individual (e.g., internalized stigma, marginalization), interpersonal (e.g., verbal abuse from healthcare providers, withholding of care), and structural levels (e.g., gender norms, power imbalances).
Thirsk LM, Panchuk JT, Stahlke S, et al. Int J Nurs Stud. 2022;133:104284.
Biases in healthcare can compromise decision-making and lead to diagnostic errors and delays in diagnosis. This scoping review examines cognitive and implicit biases in nursing care. The authors found a breadth of evidence examining the presence of cognitive and implicit biases in nursing but identified limited evidence evaluating effective debiasing interventions.
Lawson MB, Bissell MCS, Miglioretti DL, et al. JAMA Oncol. 2022;Epub Jun 23.
Delays in breast cancer diagnosis and treatment can threaten patient safety. This study analyzed data from a large US breast cancer screening consortium to evaluate differences in diagnostic follow-up among racial and ethnic groups. Findings indicate that Black women were most likely to experience diagnostic delays (between receipt of abnormal screening result to biopsy) after adjusting for individual-, neighborhood-, and health care-level factor, emphasizing the need to address the potential for systemic racism in healthcare.
Khan A, Baird JD, Kelly MM, et al. Pediatrics. 2022;149:e2021053913.
Patient and family engagement in safety efforts is supported in research but patients and clinicians still experience barriers in providing and accepting feedback. In this study, parents and caregivers of medically complex children reported uncertainty about whether and to whom to report concerns. Other themes included misalignment of staff and parent expectations of care and staff and leadership buy-in on the value of parent engagement.
Falcone ML, Van Stee SK, Tokac U, et al. J Patient Saf. 2022;18:e727-e740.
Adverse event reporting is foundational to improving patient safety, but many events go unreported. This review identified four key priorities in increasing adverse event reporting: understanding and reducing barriers; improving perceptions of adverse event reporting within healthcare hierarchies; improving organizational culture; and improving outcomes measurement.
Barnard C, Chung JW, Flaherty V, et al. Jt Comm J Qual Patient Saf. 2022;Epub Apr 28.
Organizations such as The Joint Commission and the Leapfrog Group require participating healthcare organizations to evaluate their patient safety culture, but surveys can represent a time burden on staff. An Illinois health system aimed to lessen this burden on staff by creating a shorter, revised survey. The final survey consisted of five questions with comparable measurement properties of the original 17-question survey; however, the authors caution the shorter survey will yield less detail than the longer version.
de Loizaga SR, Clarke-Myers K, R Khoury P, et al. J Patient Exp. 2022;9:237437352211026.
Parents have reported the importance of being involved in discussions with clinicians following adverse events involving their children. This study asked parents and physicians about their perspectives on inclusion of parents in morbidity and mortality (M&M) reviews. Similar to earlier studies, parents wished to be involved, while physicians were concerned that parent involvement would draw attention away from the overall purpose (e.g., quality improvement) of M&M conferences.
Dyrbye LN, West CP, Sinsky CA, et al. JAMA Netw Open. 2022;5:e2213080.
Burnout is characterized as emotional exhaustion, depersonalization, and decreased sense of accomplishment at work which results in overwhelming negative emotions. Earlier studies have focused on the association of burnout with the electronic medical record and the COVID-19 pandemic, among others. This study focused on the association of physician burnout and mistreatment by patients, families and visitors. Survey respondents reported experiencing mistreatment (e.g., racially or ethnically offensive remarks) and discrimination (e.g., patients or families refusing to allow the physician to provide treatment based on their gender, race, or ethnicity) in the past year. Experiencing mistreatment or discrimination was associated with burnout.
Joseph K, Newman B, Manias E, et al. Patient Educ Couns. 2022;105:2778-2784.
Lack of patient engagement in care can place them at increased risk for safety events. This qualitative study explored ethnic minority stakeholder perspectives about patient engagement in cancer care. Focus groups consisting of participants from consumer and health organizations involved in cancer care in Australia identified three themes supporting successful engagement – consideration of sociocultural beliefs about cancer, adaptation of existing techniques tailored to stakeholders (e.g., culturally specific content), and accounting for factors such as cultural competence during implementation.
Gupta K, Rivadeneira NA, Lisker S, et al. J Patient Saf. 2022;Epub Apr 27.
Strategies to reduce clinician burnout related to adverse events are critically needed. Physicians in the United States were surveyed on their experiences with adverse events to identify facilitators and barriers to reducing burnout. A common facilitator was peer support, and barriers included shame and a punitive work environment.
Sederstrom N, Lasege T. Hastings Cent Rep. 2022;52:s24-s29.
Racial bias and systemic racism in healthcare are increasingly seen as critical patient safety issues. This commentary discusses the relationship between medical ethics and racism in healthcare institutions, using examples such as racial biases in clinical tools and algorithms, the effect of racial bias on diagnosis and diagnostic error, and how excess disease burden can be viewed as proxy for racism.
Buhlmann M, Ewens B, Rashidi A. J Adv Nurs. 2022;Epub Apr 22.
The term “second victims” describes clinicians who experience emotional or physical distress following involvement in an adverse event. Nurses and midwives were interviewed about “moving on” from the impact of a critical incident. Five main themes were identified: Initial emotional and physical response, the aftermath, long-lasting repercussions, workplace support, and moving on. Lack of organizational support exacerbated the nurses’ and midwives’ responses.
Sosa T, Galligan MM, Brady PW. J Hosp Med. 2022;17:199-202.
Situation awareness supports effective teamwork and safe care delivery. This commentary highlights the role of situation awareness in watching the condition of pediatric inpatients to reduce instances of unrecognized clinical deterioration. It features rapid response models enhanced by event review, psychological safety, and patient and family partnering as mechanisms improved through situation awareness.
Riblet NB, Gottlieb DJ, Watts BV, et al. J Nerv Ment Dis. 2022;210:227-230.
Unplanned discharges (also referred to as leaving against medical advice) can lead to adverse patient outcomes. This study compared unplanned discharges across Veterans Health Affairs (VHA) acute inpatient and residential mental health treatment settings over a ten-year period and found that unplanned discharges are significantly higher in mental health settings. The authors recommend that unplanned discharges be measured to assess patient safety in mental health.