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Mercer K, Carter C, Burns C, et al. JMIR Hum Factors. 2021;8(4):e22325.
Clear communication regarding medication indications can improve patient safety. This scoping review explored how including the indication on a prescription may impact prescribing practice. Studies suggest that including the indication can help identify errors, support communication, and improve patient safety, but prescribers noted concerns about impacts on workflow and patient privacy.
Ranji SR, Thomas EJ. BMJ Qual Saf. 2022;Epub Jan 5.
Diagnostic safety interventions have been empirically evaluated but real-world implementation challenges persist. This commentary discusses the importance of incorporating contextual factors (e.g., social, cultural) facing complex healthcare systems into the design of diagnostic safety interventions. The authors provide recommendations for designing studies to improve diagnosis that take contextual factors into consideration.
Lederman J, Lindström V, Elmqvist C, et al. BMC Emerg Med. 2021;21(1):154.
Patients who are treated by emergency medical services (EMS) personnel but not transported to the hospital are referred to as non-conveyed patients. In this retrospective cohort study, researchers found that older adult patients in Sweden are at an increased risk of adverse events (such as infection, hospitalization, or death) within 7-days following non-conveyance.
Grauer A, Kneifati-Hayek J, Reuland B, et al. J Am Med Inform Assoc. 2021;Epub Dec 28.
Problem lists, while an important part of high-quality care, are frequently incomplete or lack accuracy. This study examined the effectiveness of leveraging indication alerts in electronic health records (EHR) (medication ordered lacking a corresponding problem on the problem list) in two different hospitals using different EHRs. Both sites resulted in a proportion of new problems being added to the problem list for the medications triggered. Between 9.6% and 11.1% were abandoned (order started but not signed), which needs further study.
Saliba R, Karam-Sarkis D, Zahar J-R, et al. J Hosp Infect. 2022;119:54-63.
Patient isolation for infection prevention and control may result in unintended consequences. This systematic review examined adverse physical and psychosocial events associated with patient isolation. A meta-analysis of seven observational studies showed no adverse events related to clinical care or patient experience with isolation.
Lyndon A, Simpson KR, Spetz J, et al. Appl Nurs Res. 2022;63:151516.
Missed nursing care appears to be associated with higher rates of adverse events. More than 3,600 registered nurses (RNs) were surveyed about missed care during labor and birth in the United States. Three aspects of nursing care were reported missing by respondents: thorough review of prenatal records, missed timely documentation of maternal-fetal assessments, and failure to monitor input and output.
FitzGerald C, Hurst S. BMC Med Ethics. 2017;18(1):19.
Healthcare provider implicit bias can lead to inequitable care delivery and poor patient outcomes. This review identified 42 articles about healthcare professional implicit biases, including gender, race, ethnicity, and age. Biases were detected in provider attitudes, treatment decisions, and diagnosis.
Noor Arzahan IS, Ismail Z, Yasin SM. Safety Sci. 2022;147:105624.
A culture of safety is a key component to successful patient safety initiatives. This systematic review explored the relationship between safety culture and safety climate dimensions and safety performance measures. The most common dimensions used to assess this relationship were the involvement of leadership, safety resources, risk management and communication, safety rules and procedures, and involvement of healthcare workers.
Kemp T, Butler‐Henderson K, Allen P, et al. Health Info Libr J. 2021;38(4):248-258.
This review focused on the impact of the Health Information Management (HIM) profession on patient safety as it relates to health information documentation. Key themes identified were data quality, information governance, corporate governance, skills, and knowledge required for HIM professionals.
Bryant BE, Jordan A, Clark US. JAMA Psych. 2021;Epub Dec 8.
Research and medical practice are negatively affected by systemic and implicit bias. This commentary discusses this phenomenon in the mental health sector and suggests a role for researchers to reduce the inappropriate use of race in psychiatric practice while limiting its detrimental impact on care nationwide.
Okpalauwaekwe U, Tzeng H-M. Patient Relat Outcome Meas. 2021;12:323-337.
Patients transferred from hospitals to skilled nursing facilities (SNFs) are vulnerable to adverse events. This scoping review identified common extrinsic factors contributing to adverse events among older adults during rehabilitation stays at skilled nursing facilities, including inappropriate medication usage, polypharmacy, environmental hazards, poor communication between staff, lack of resident safety plans, and poor quality of care due to racial bias, organizational issues, and administrative issues.
Gillespie BM, Harbeck EL, Rattray M, et al. Int J Surg. 2021;95:106136.
Surgical site infections (SSI) are a common, yet largely preventable, complication of surgery which can result in increased length of stay and hospital readmission. In this review of 57 studies, the cumulative incidence of SSI was 11% in adult general surgical patients and was associated with increased length of stay (with variation by types of surgery).
Fischer T, Tian AW, Lee A, et al. The Leadership Q. 2021;32(6):101540.
While leaders and supervisors are responsible for ensuring a professional and respectful work environment, some may display disruptive and unprofessional behavior themselves. This systematic and critical review of abusive supervision research identified four major challenges facing the field, explaining how each challenge has limited past research, and offers recommendations for future research.
Kuznetsova M, Frits ML, Dulgarian S, et al. JAMIA Open. 2021;4(4):ooab096.
Dashboards can be used to synthesize data and visualize patient safety indicators and metrics to facilitate decision-making. The authors reviewed design features of patient safety dashboards from 10 hospitals and discuss the variation in the use of performance indicators, style, and timeframe for displayed metrics. The authors suggest that future research explore how specific design elements contribute to usability, and which approaches are associated with improved outcomes.
Nassery N, Horberg MA, Rubenstein KB, et al. Diagnosis (Berl). 2021;8(4):469-478.
Building on prior research on missed myocardial infarction, this study used the SPADE approach to identify delays in sepsis diagnosis. Using claims data, researchers used a ‘look back’ analysis to identify treat-and-release emergency department (ED) visits in the month prior to sepsis hospitalizations and identify common diagnoses linked to downstream sepsis hospitalizations.

Society to Improve Diagnosis in Medicine.

The impact of diagnostic error is increasingly clarified as research defines primary areas of concern. This grant program will provide 20 seed grants to multidisciplinary teams that include patients. The work will devise and test interventions to improve the diagnostic process. The 2022 application process closes March 25, 2022.
Walshe N, Ryng S, Drennan J, et al. Int J Nurs Stud. 2021;124:104086.
Situation awareness refers to the degree to which perception matches reality. This narrative review explored how situation awareness has been defined and studied in healthcare, with a particular focus on nursing. Three overarching themes were identified: (1) individual, team and systems perspectives of situation awareness; (2) situation awareness and patient safety, and (3) communication tools, technologies and education to support situation awareness. The authors note that future research should reflect nurse’s work and the constrictions imposed on situation awareness by the demands of busy impatient wards.
Bennion J, Mansell SK. Br J Hosp Med (Lond). 2021;82(8):1-8.
Many strategies have been developed to improve recognition of, and response, to clinically deteriorating patients. This review found that simulation-based educational strategies was the most effective educational method for training staff to recognize unwell patients. However, the quality of evidence was low and additional research into simulation-based education is needed.
Townsend T, Cerdá M, Bohnert AS, et al. Health Aff (Millwood). 2021;40(11):1766-1775.
Misuse of prescription opioids represents a serious patient safety issue. Using commercial claims from 2014 - 2018, researchers examined the association between the 2016 CDC guidelines to reduce unsafe opioid prescribing and opioid dispensing for patients with four common chronic pain diagnoses. Findings indicate that the release of the 2016 guidelines was associated with reductions in the percentage of patients receiving opioids, average dose prescribed, percentage receiving high-dose prescriptions, number of days supplied, and the percentage of patients receiving concurrent opioid/benzodiazepine prescriptions. The authors observe that questions remain about how clinicians are tailoring opioid reductions using a patient-centered approach.