The PSNet Collection

A checklist to address implicit bias in healthcare settings during the COVID-19 pandemic: The PLACE Strategy.

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Galiatsatos P, O'Conor KJ, Wilson C, et al. Health Secur. 2022;Epub Apr 26.

Stressful situations can degrade communication, teamwork and decision making. This commentary describes a program to minimize the potential impact of implicit biases in a crisis. Steps in the process include Pausing to Listen, working to Ally and Collaborate, and seeking to Empower patients and staff members.

The Color of Care.

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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.

A Virtual Hospitalist Program to Address a Hospital’s Challenges at the Start of the COVID-19 Pandemic

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April 27, 2022

In the early days of the COVID-19 pandemic, New York Presbyterian Weill Cornell Medical Center and Lower Manhattan Hospital faced multiple challenges.

Prescribing errors in post-COVID-19 patients: prevalence, severity, and risk factors in patients visiting a post-COVID-19 outpatient clinic.

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Mahomedradja RF, van den Beukel TO, van den Bos M, et al. BMC Emerg Med. 2022;22:35.

The potential for medication errors may increase due to redeployment and reorganization of hospital resources during COVID-19 surges. In this study of patients hospitalized during the first wave of the pandemic, over 90% had at least one prescribing error three months after hospitalization. Intensive care unit admission and a history of chronic obstructive pulmonary disease (COPD) or asthma were risk factors for prescribing errors. Acknowledging and understanding these risk factors allows hospital leadership to target interventions for this population.

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

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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

COVID-19 and Dentistry: Challenges and Opportunities for Providing Safe Care

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February 23, 2022

This publication serves as an update to the PSNet Primer released in August 2020. This content describes the outbreak of coronavirus disease 2019 (COVID-19), which effectively shut down the practices of approximately 198,000 active dental practitioners in the USA.

Factors associated with missed nursing care and nurse-assessed quality of care during the COVID-19 pandemic.

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Labrague LJ, Santos JAA, Fronda DC. J Nurs Manag. 2022;30:62-70.

Missed or incomplete nursing care can adversely affect care quality and safety. Based on survey responses from 295 frontline nurses in the Philippines, this study explored factors contributing to missed nursing care during the COVID-19 pandemic. Findings suggest that nurses most frequently missed tasks such as patient surveillance, comforting patients, skin care, ambulation, and oral hygiene. The authors suggest that increasing nurse staffing, adequate use of personal protective equipment, and improved safety culture may reduce instances of missed care.

Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic

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January 12, 2022

This piece discusses patient safety challenges that arose as a result of the unique care circumstances surrounding the COVID-19 pandemic, particularly at the height of the pandemic in 2020.

In conversation with Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO

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January 12, 2022

Patient Safety Organizations (PSOs) are organizations dedicated to improving patient safety and healthcare quality that serve to collect and analyze data voluntarily reported by healthcare providers to promote learning.

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

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January 11, 2022

Diagnostic error has been increasingly recognized as an important and evolving patient safety issue. This Primer applies well-established principles of diagnostic error and improvement of diagnostic accuracy to the topic of COVID-19.

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.

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ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares reported vaccine errors and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.

The COVID trap: pediatric diagnostic errors in a pandemic world.

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Fatemi Y, Coffin SE. Diagnosis (Berl). 2021;8:525-531.

Using case studies, this commentary describes how availability bias, diagnostic momentum, and premature closure resulted in delayed diagnosis for three pediatric patients first diagnosed with COVID-19. The authors highlight cognitive and systems factors that influenced this diagnostic error.

Patient factors and hospital outcomes associated with atypical presentation in hospitalized older adults with COVID-19 during the first surge of the pandemic.

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Marziliano A, Burns E, Chauhan L, et al. J Gerontol A Biol Sci Med Sci. 2022;77:e124-e132.

Many COVID-19 patients present with atypical symptoms, such as delirium, smell and taste dysfunction, or cardiovascular features. Based on inpatient electronic health record data between March 1 and April 20 of 2020, this cohort study examined the frequency of atypical presentation of COVID-19 among older adults. Analyses suggest that atypical presentation was often characterized by functional decline or altered mental status.

Patient safety in dermatology: a ten-year update.

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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.

Clinical characteristics and short-term outcomes of acute kidney injury missed diagnosis in older patients with severe COVID-19 in intensive care unit.

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Li Q, Hu P, Kang H, et al. J Nutr Health Aging. 2020;25:492-500.

Missed and delayed diagnosis are a known cause of preventable adverse events. In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury (AKI). However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed AKI. Involvement of intensive care kidney specialists is recommended to increase diagnostic awareness.

A Postpartum Woman with an Erroneous SARS-CoV-2 Test

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April 28, 2021

A pregnant patient was admitted for scheduled Cesarean delivery, before being tested according to a universal inpatient screening protocol for SARS-CoV-2. During surgery, the patient developed a fever and required oxygen supplementation. Due to suspicion for COVID-19, a specimen obtained via nasopharyngeal swab was sent to a commercial laboratory for reverse transcriptase polymerase chain reaction (RT-PCR) testing.

Drug-drug interactions and prescription appropriateness at hospital discharge: experience with COVID-19 patients.

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Cattaneo D, Pasina L, Maggioni AP, et al. Drugs Aging. 2021;38:341-346.

Older adults are at increased risk of hospitalization due to COVID-19 infections. This study examined the potential severe drug-drug interactions (DDI) among hospitalized older adults taking two or more medications at admission and discharge. There was a significant increase in prescription of proton pump inhibitors and heparins from admission to discharge. Clinical decision support systems should be used to assess potential DDI with particular attention paid to the risk of bleeding complications linked to heparin-based DDIs.

Could Efforts to Fight the Coronavirus Lead to Overuse of Antibiotics?

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Issue Brief. Washington DC: Pew Charitable Trust; March 2021.

Antibiotic overuse is a contributor to nosocomial infection. This report discusses problems associated with antibiotic prescribing during the first 6 months of the COVID-19 pandemic. Systemic problems arising from the situation include disparities associated with antibiotic administration and unneeded receipt of medications by some patients.

What COVID-19 teaches us about implicit bias in pediatric health care.

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Mulchan SS, Wakefield EO, Santos M. J Ped Psychol. 2021;46:138-143.

Implicit and explicit bias can reduce the effectiveness and safety of care. Based on a review of the literature, the authors conclude that the strain placed on provider resources, staff, and supplies by the COVID-19 pandemic may exacerbate implicit bias among pediatric providers. The authors discuss implicit bias at the individual, organizational, educational, and research levels, provide specific calls to action for pediatric healthcare providers, and discuss the role of pediatric psychologists in supporting other providers.

Drug shortages amid the COVID-19 pandemic.

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Bookwalter CM. US Pharmacist. 2021;46(2):25-28.

COVID-19 has increased uncertainties in sectors across health care. This article discusses a variety of supply-chain factors that impact medication availability. The author suggests roles for pharmacists in antibiotic stewardship and policy implementation to manage shortages safely.

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