Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
1 - 20 of 2230
Rosen PD, Klenzak S, Baptista S. J Fam Pract. 2022;71:124-132.
Cognitive biases can impede decision-making and lead to poor care. This article summarizes the common types of cognitive errors and biases and highlights how cognitive biases can contribute to diagnostic errors. The authors apply these common types of errors and biases in four case examples and discuss how to mitigate these biases during the diagnostic process. 
Alpert AB, Mehringer JE, Orta SJ, et al. J Gen Intern Med. 2022;Epub May 31.
Transgender patients who experience or perceive bias when receiving care may avoid or delay seeking care in the future. In this study, transgender patients reported on their experiences in viewing their electronic health record (EHR). In line with previous studies, transgender patients reported experiencing harms in several ways, such as providers using the wrong pronouns, wrong name, or wrong gender marker. The structure of the EHR (e.g., no separate fields for sex and gender) itself also created barriers to quality care.
Bender JA, Kulju S, Soncrant C. Jt Comm J Qual Patient Saf. 2022;48:326-334.
Healthcare organizations use multiple proactive and reactive methods of investigating and preventing adverse events. This study combined proactive and reactive risk assessments into a Combined Proactive Risk Assessment (CPRA) to identify risks not detected by one method on its own. The four steps of CPRA are illustrated using the example of outpatient blood draws in the Veterans Health Administration.
Gleeson LL, Ludlow A, Wallace E, et al. Explor Res Clin Soc Pharm. 2022;6:100143.
Primary care rapidly shifted to telehealth and virtual visits at the start of the COVID-19 pandemic. This study asked general practitioners (GPs) and pharmacists in Ireland about the impact of technology (i.e., virtual visits, electronic prescribing) on medication safety since the pandemic began. Both groups identified electronic prescribing as the most significant workflow change. GPs did not perceive a change in medication safety incidents due to electronic prescribing; pharmacists reported a slight increase in incidents.
Cedillo G, George MC, Deshpande R, et al. Addict Sci Clin Pract. 2022;17:28.
In 2016, the Centers for Disease Control (CDC) issued an opioid prescribing guideline intended to reverse the increasing death rate from opioid overdoses. This study describes the development, implementation, and effect of a safe prescribing strategy (TOWER) in an HIV-focused primary care setting. Providers using TOWER were more adherent to the CDC guidelines, with no worsening patient-reported outcome measures.

ISMP Medication Safety Alert! Acute care edition. June 2, 2022;27(11):1-4.

Minimizing look-alike/sound-alike medication risk is a universal need across health care. This story highlights a primary prevention tool that lists problematic drug names. It shares strategies across the medication use process to reduce errors associated with similarly named and labeled medications such as separate storage areas and tall man lettering.
Fontil V, Khoong EC, Lyles C, et al. Jt Comm J Qual Patient Saf. 2022;Epub May 5.
Missed or delayed diagnosis in primary care may result in serious complications for patients. This prospective study followed adults presenting to primary care with new or unresolved symptoms for 12 months. 32% of patients received a diagnosis within one month; most of the rest still did not have a diagnosis at 12 months (50%). The authors suggest interventions aimed at improving diagnosis should be system-based, not specific to a single medical issue or population.
Salema N-E, Bell BG, Marsden K, et al. BJGP Open. 2022;Epub May 6.
Medication prescribing errors are common, particularly during medical training. This retrospective review of prescriptions from ten general practitioners in training in the United Kingdom identified a high rate of prescribing errors (8.9% of prescriptions reviewed) and suboptimal prescribing (35%).
Butler AM, Brown DS, Durkin MJ, et al. JAMA Netw Open. 2022;5:e2214153.
Inappropriately prescribing antibiotics for non-bacterial infections remains common in outpatient settings despite the associated risks. This analysis of antibiotics prescribed to more than 2.8 million children showed more than 30% of children with bacterial infection, and 4%-70% of children with viral infection were inappropriately prescribed antibiotics. Inappropriate prescribing led to increased risk of adverse drug events (e.g., allergic reaction) and increased health expenditures in the following 30 days.
Appelbaum NP, Santen SA, Perera RA, et al. J Patient Saf. 2022;18:370-375.
Residents and trainees frequently report experiencing bullying and disrespectful behaviors in the workplace. This study explored the relationship between resident psychological safety, perceived organizational support, and humiliation. Results indicate resident perception of increased organizational support (e.g., help is available when they have a problem) reduces the negative impact of humiliation on their psychological safety.
Prudenzi A, D. Graham C, Flaxman PE, et al. Psychol Health Med. 2022;27:1130-1143.
Previous research has found that mindfulness interventions can reduce stress and burnout among physicians. This survey of 98 healthcare workers within the UK National Health Service (NHS) explored the relationship between poor wellbeing, burnout and perceived safe practice and identified a positive relationship between mindfulness processes and perceived safe practices.
Smith M, Vaughan Sarrazin M, Wang X, et al. J Am Geriatr Soc. 2022;70:1314-1324.
The COVID-19 pandemic disrupted healthcare delivery and contributed to delays in care. Based on a retrospective matched cohort of Medicare patients, this study explored the impact of the COVID-19 pandemic on patients who may be at risk for missed or delayed care. Researchers found that patients with four or more indicators for risk of missed or delayed care (e.g., chronic conditions, frailty, disability affecting use of telehealth) had higher mortality and lower rates of healthcare utilization, including primary care visits.
Jambon J, Choukroun C, Roux-Marson C, et al. Clin Neuropharmacol. 2022;45:65-71.
Polypharmacy in older adults is an ongoing safety concern due to the risk of being prescribed a potentially inappropriate medication or co-prescription of medications with dangerous interactions. In this study of adults aged 65 and older with chronic pain, 54% were taking at least one potentially inappropriate medication and 43% were at moderate or high risk of adverse drug events. Measures such as involvement of a pharmacist in medication review could reduce risk of adverse drug events in older adult outpatients.
Shiner B, Gottlieb DJ, Levis M, et al. BMJ Qual Saf. 2022;31:434-440.
Previous research has emphasized suicide prevention in inpatient mental health settings, but less is known about suicide in outpatient settings. Using longitudinal data from 2013 to 2017, this study found no relationship between overall quality of outpatient mental healthcare and suicide rates among patients treated by the Veterans Health Administration healthcare system.

Armstrong Institute for Patient Safety and Quality. September 22-23, 2022.

The comprehensive unit-based safety program (CUSP) approach emphasizes active teamwork as a core element of improving safety culture through reporting and learning from errors. This virtual conference will cover how to engage teams in the ambulatory environment, address barriers to safe care, and learn from the experiences of others.
Buitrago I, Seidl KL, Gingold DB, et al. J Healthc Qual. 2022;44:169-177.
Reducing hospital 30-day readmissions is seen as a way to improve safety and reduce costs. Baltimore City mobile integrated health and community paramedicine (MIH-CP) was designed to improve transitional care from hospital to home. After one year in operation, MIH-CP performed a chart review to determine causes of readmission among patients in the program. Root cause analysis indicated that at least one social determinant of health (e.g., health literacy) played a role in preventable readmissions; the program was modified to improve transitional care.
Johansson H, Lundgren K, Hagiwara MA. BMC Emerg Med. 2022;22:79.
Emergency medical services (EMS) clinicians must decide whether to transport patients to hospitals for emergency care, what level of emergency care they require, or to treat the patient at home and not transport to hospital. This analysis focused on patient safety incidents in Swedish prehospital care that occurred after 2015, following implementation of a protocol allowing EMS clinicians to triage patients to see-and-treat (non-conveyance) or see-and-convey elsewhere. Qualitative analysis of incident reports revealed three themes: assessment of patients, guidelines, and environment and organization. EMS clinicians deviated from the protocol in 34% of cases, putting patients at risk of inappropriate triage to see-and-treat.
Molist-Brunet N, Sevilla-Sánchez D, Puigoriol-Juvanteny E, et al. Int J Environ Res Public Health. 2022;19:3423.
Inappropriate prescribing and polypharmacy can place older adults at increased risk for medication-related adverse events. This study found that up to 90% of older adults had at least one inappropriate prescription, regardless of residential setting but medication review resulted in a greater decrease in risk factors for medication-related adverse events (e.g., polypharmacy, therapeutic complexity) among nursing home patients compared to patients living at home.
Rotenstein LS, Melnick ER, Sinsky CA. JAMA. 2022;327:2079-2080.
Clinician well-being is increasingly seen as a quality and safety issue. This commentary discusses how systemic efforts must be built to enhance occupational well-being among clinicians. This approach discussed should consider both human factors and organizational design strategies to reduce burnout, cognitive overload, process frustration, and technology use.