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Fawzy A, Wu TD, Wang K, et al. JAMA Intern Med. 2022;Epub May 31.
Black and brown patients have experienced disproportionately poorer outcomes from COVID-19 infection as compared with white patients. This study found that patients who identified as Asian, Black, or Hispanic may not have received timely diagnosis or treatment due to inaccurately measured pulse oximetry (SpO2). These inaccuracies and discrepancies should be considered in COVID outcome research as well as other respiratory illnesses that rely on SpO2 measurement for treatment.

ECRI. Plymouth Meeting, PA. March 2022.

The global COVID-19 pandemic has exacerbated patient safety concerns. ECRI presents the top ten patient concerns for 2022, including staffing challenges, human factors in telehealth, and supply chain disruptions.
Fakih MG, Bufalino A, Sturm L, et al. Infect Control Hosp Epidemiol. 2021;43:26-31.
Central line-associated blood steam infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) prevention were an important part of patient safety prior to the COVID-19 pandemic. This study compared CLABSI and CAUTI rates in 78 hospitals during the 12-month period prior to the pandemic and the first 6 months of the pandemic. CLABSI rates increased by 51% during the pandemic period, mainly in the ICU. CAUTI rates did not show significant changes.

National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. December 6, 2021. 

Vaccine missteps are known to occur during flu and COVID-19 inoculation efforts. This announcement raises awareness of misadministration of COVID vaccines associated with patient age. It highlights storage protocols as one approach to minimize mistakes. This alert is part of a national program to distribute learnings from report analysis to improve medication safety.
Ellis R, Hardie JA, Summerton DJ, et al. Surg. 2021;59:752-756.
Many non-urgent, non-cancer surgeries were postponed or canceled during COVID-19 surges resulting in a potential loss of surgeons’ “currency”. This commentary discusses the benefits of, and barriers to, dual surgeon operating as a way to increase currency as elective surgeries are resumed.
Taylor M, Reynolds C, Jones RM. Patient Safety. 2021;3:45-62.
Isolation for infection prevention and control – albeit necessary – may result in unintended consequences and adverse events. Drawing from data submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers explored safety events that impacted COVID-19-positive or rule-out status patients in insolation. The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related events.
Dhahri AA, Refson J. BMJ Leader. 2021;5:203-205.
Hierarchy and professional silos can disrupt collaboration. This commentary describes one hospital’s approach to shifting the surgical leadership role to facilitate communication and cross-organizational influence to affect quality and safety performance.

Patel J, Otto E, Taylor JS, et al. Dermatol Online J. 2021;27(3).

In an update to their 2010 article, this review’s authors summarized the patient safety literature in dermatology from 2009 to 2020. In addition to topics covered in the 2010 article, this article also includes diagnostic errors related to telemedicine, laser safety, scope of practice, and infections such as COVID-19. The authors recommend further studies, and reports are needed to reduce errors and improve patient safety.
Kakemam E, Chegini Z, Rouhi A, et al. J Nurs Manag. 2021;29:1974-1982.
Clinician burnout, characterized by emotional exhaustion, depersonalization, and decreased sense of accomplishment, can result in worse patient safety outcomes. This study explores the association of nurse burnout and self-reported occurrence of adverse events during COVID-19. Results indicate higher levels of nurse burnout were correlated with increased perception of adverse events, such as patient and family verbal abuse, medication errors, and patient and family complaints. Recommendations for decreasing burnout include access to psychosocial support and human factors approaches.
Della Torre V, E. Nacul F, Rosseel P, et al. Anaesthesiol Intensive Ther. 2021;53:265-270.
Human factors (HF) is the interaction between workers, equipment, and the environment. The COVID-19 pandemic has accelerated the adoption of HF in intensive care units across the globe. This paper expands on the core concepts of HF and proposes the additional key concepts of agility, serendipity, innovation, and learning. Adoption of these HF concepts by leadership and staff can improve patient safety in intensive care units in future pandemics and other crisis situations.
Zhang T, Mosier J, Subbian V. JMIR Hum Factors. 2021;8:e24860.
The increased use of telehealth during the COVID-19 pandemic has not been without challenges. This article uses the Systems Engineering Initiative for Patient Safety (SEIPS) model to assess barriers related to telehealth implementation during the pandemic and the impact on patients, providers, technology, care processes, organizations, and the environment.

In this PSNet Annual Perspective, we worked with co-authors Dr. Jacqueline C. Stocking, a quality improvement and critical care specialist, and Dr. Christian Sandrock, a patient safety professional and emerging infectious diseases specialist, to provide a look at news and research related to the impact of the COVID-19 pandemic on patient safety.

Panda N, Etheridge JC, Singh T, et al. World J Surg. 2021;45:1293-1296.
The World Health Organization (WHO) surgical safety checklist is widely used in surgical settings to prevent errors. This multinational panel representing multiple clinical specialties identified 16 recommendations for checklist content modification and implementation during the COVID-19 pandemic. These recommendations exemplify how the checklist can be adapted to meet urgent and emerging needs of surgical units by targeting important processes and encouraging critical discussions.

La Regina M, Tanzini M, Venneri F, et al for the Italian Network for Health Safety. Dublin, Ireland: International Society for Quality in Health Care; 2021.

The COVID-19 pandemic is a rapidly evolving situation that requires a system orientation to diagnosis, management and post-acute care to keep clinicians, patients, families and communities safe. This set of recommendations is anchored on a human factors approach to provide overarching direction to design systems and approaches to respond to the virus. The recommendations focus on team communication and organizational culture; the diagnostic process; patient and family engagement to reduce spread; hospital, pediatric, and maternity processes and treatments; triage decision ethics; discharge communications; home isolation; psychological safety of staff and patients, and; outcome measures. An appendix covers drug interactions and adverse effects for medications used to treat this patient population. The freely-available full text document will be updated appropriately as Italy continues to respond, learn and amend its approach during the outbreak.

Toccafondi G, Di Marzo F, Sartelli M, et al. Int J Qual Health Care. 2021;33(Supp 1):51-55. 

 

The impact of the COVID-19 pandemic on infection prevention efforts and healthcare-associated infections is unclear. This article discusses how the COVID-19 pandemic has led to adaptations to infection prevention and control and surveillance (IPCS) practices and a human factors and ergonomics perspective in surgery. Leveraging lessons learned from the pandemic, the authors use a human factors perspective to propose an enhanced infection prevention and control approach to prevent surgical site infections. 
Abreu Saurin T. Safety Sci. 2021;134:105087.
The COVID-19 pandemic has raised new challenges and opportunities for quality improvement and safety science.The authors use a complexity thinking (understanding the dynamic interactions between systems) perspective to discuss the pandemic as a safety science problem with corresponding risk mitigation measures.
Britton CR, Hayman G, Stroud N. J Perioper Pract. 2021;31:44-50.
The COVID-19 pandemic has highlighted the crucial role that team and human factors play in healthcare delivery. This article describes the impact of a human factors education and training program focused on non-technical skills and teamwork (the ONSeT project) – on operating room teams during the pandemic. Results indicate that the project improved team functioning and team leader responsiveness.
Alagha MA, Jaulin F, Yeung W, et al. J Patient Saf. 2021;17:87-89.
This article uses an adapted human factors analysis classification system (HFACS) to describe three levels of failure occurring during the COVID-19 pandemic: organizational factors (e.g., resource management, organizational climate), individuals and their environments (e.g., lack of training in  personal protective equipment (PPE) donning), and supervision factors (such as those caused by staffing shortages).
Traylor AM. Am Psychol. 2021;76:1-13.
The COVID-19 pandemic has dramatically affected the psychological and emotional well-being of health care workers. This article summarizes the COVID-19-related psychological effects on healthcare workers and the detrimental impact on team effectiveness. The authors recommended actions to mitigate the effects of stress on team performance and patient outcomes and discuss how teams can recover and learn from the current crisis to prepare for future challenges.
Gavin N, Romney M-LS, Lema PC, et al. BMJ Leader. 2021;5:39-41.
Developed in the field of aviation, crew resource management (CRM) is used to teach teamwork and effective communication and has been used extensively in patient safety improvement efforts. This commentary describes four New York metropolitan area emergency departments’ experience applying (CRM) principles at an organizational level in responding to the current COVID-19 pandemic as well as future crises.