The PSNet Collection

Fostering ethical conduct through psychological safety.

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Ferrere A, Rider C, Renerte B et al. Sloan Manag Rev. Summer 2022;39-43.

A baseline expectation in a safe organization is that employees feel comfortable and supported when sharing concerns. This article summarizes key results of a large workplace survey to identify cultural elements supporting the psychological safety required to encourage speaking up when ethical or other issues are identified in operations.

Stop using these adult bed rails, warns the Consumer Product Safety Commission.

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Treisman R. National Public Radio. June 6, 2022

Bedrails are used in hospitals and at home to minimize falls despite the potential to contribute to patient harm. This news article summarizes a government recall of ten models of home bed rail devices due to entrapment incidents.

Anesthesiologist group says hospitals can prevent fatal errors like Vanderbilt's.

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Clark C. MedPage Today. June 2, 2022

Transparency and discussion of errors is a hallmark of the culture needed to improve safety. This article summarizes an Anesthesia Patient Safety Foundation statement directing organizations and individuals that provide anesthesia care to protect patients and encourage learning from error. It provides context through a discussion of official reports and investigations of a high-profile incident that culminated in criminal charges for the clinician involved.

Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups.

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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.

Are you well positioned to resolve conflicts with the safety of an order? Learning from a physician’s homicide trial and the firing of multiple healthcare workers.

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ISMP Medication Safety Alert! Acute care edition. May 19, 2022;27(10):1-5.

Challenging authority can be difficult but necessary in risky situations. This article examines a serial euthanasia overdose case and how the individuals interfacing with the physician involved sensed the medications ordered were inappropriate, yet said nothing. The piece discusses organizational and individual steps to encourage raising concerns in an appropriate and effective manner.

CMS proposal to suppress hospital safety data angers advocates — agency says COVID disruptions, staff shortages hamper ability to fairly score poor performers.

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Clark C. MedPage Today. May 20, 2022.

Public reporting of safety measures is considered a hallmark of health care transparency. This article discusses a proposed change to reporting requirements in the Hospital-Acquired Condition Reduction Program (HACRP). The change would limit the sharing of patient safety indicator data that informs Care Compare and hospital Medicare reimbursements.

4 actions to reduce medical errors in U.S. hospitals.

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Toussaint JS, Segel KT. Harvard Business Review. April 20, 2022.

The patient safety movement has had mixed results in sustaining improvement and commitment. This commentary discusses strategies to instigate continued energy toward reducing medical error: prioritization of patient safety as a hospital imperative, formation of a National Patient Safety Board, installation of a single national body for incident reporting, and implementation of electronic health record learning systems that flag potential risks.

Survey shows room for improvement with three new best practices for hospitals.

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Medication Safety Alert! Acute care edition. May 5, 2022;27(9):1-5.

Practice changes take time to be fully incorporated into daily work. This article shares survey results examining how hospitals implement best practices to enhance the safe use of oxytocin, improve vaccine administration through bar coding, and deploy multifaceted strategies to reduce high-alert medication errors. Gaps in uptake were reviewed and recommendations for improvement shared.

At US hospitals, a drug mix-up is just a few keystrokes away.

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Kelman B. Kaiser Health News. April 29, 2022.

Technological solutions harbor unique risks that can result in patient harm. This article shares a response to reports of automated dispensing cabinet (ADC) menu selection limitations that contribute to mistakes. The piece suggests the implementation of a 5-letter search requirement prior to removing a medication from an ADC. It provides an update on industry response to this forcing function recommendation.

Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety.

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ISMP Medication Safety Alert! Acute care edition. April 7, 2022; 27(2):1-6.

The Institute for Safe Medication Practices (ISMP) highlights the negative impacts the recent criminal conviction of a nurse could have for patient safety, including fear of reporting errors and clinicians leaving the profession.

Patients should know who's operating, surgeons say.

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Laber-Warren E. MedPage Today. April 5, 2022.

Resident autonomy is an essential component to medical training, but it is not without patient safety risks. This news article highlights situations where resident autonomy should be disclosed to patients (such as instances of overlapping surgeries) and the value of transparency about the role of surgical team members.

Will prosecuting medical errors lead to a culture of silence?

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Fiore K. MedPage Today. March 28, 2022.

Experts are concerned that convictions for medical error have the potential to limit dialogue on the front line about medical mistakes. This article summarizes discussions regarding the verdict to convict a nurse due to a workaround that resulted in a medication error and patient death.

As a nurse faces prison for a deadly error, her colleagues worry: could I be next?

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Kelman B. Kaiser Health News. March 22, 2022

Criminalization of medical mistakes typifies the blame-focused approach patient safety leaders have worked to reduce in health care. This article covers a high-profile case of medication error involving an automated dispensing system that is ubiquitous in health care.

Nowhere is safe: record number of patients contracted Covid in the hospital in January.

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Levy R, Vestal AJ. Politico. February 19, 2022.

Transmission of COVID-19 in the health care setting continues to be a concern. This article discusses an analysis of US government statistics tracking hospital-acquired COVID-19 infections and reasons that control efforts may be lagging, which include visitor masking choices and health care worker return to work post-COVID-19 behaviors.

Three new best practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals.

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ISMP Medication Safety Alert! Acute care edition. February 10, 2022:27(3):1-6.

Best practices evolve over time, given experience and evidence associated with their use. This article summarizes 3 new areas of focus included in current recommendations for sustaining medication safety. The new practices focus on improving the safety of oxytocin use, enhancing vaccine administration through bar coding, and implementing multifocal efforts to reduce high-alert medication errors. A survey accompanies the article to gather data on the presence of the new recommendations in the field.

Start the year off right by addressing these top 10 medication safety concerns from 2021

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Medication Safety Alert! Acute care edition. January 27, 2022;27(2):1-6.

Medication errors are a consistent threat to safe patient care. This newsletter article analyzes events submitted to the Institute for Safe Medication Practices in 2021 and highlights those that are COVID-related or common, yet preventable, if practice recommendations and system improvements are applied.

Curated Libraries

Medication/Drug Errors

Adverse glycemic events and critical emergencies.

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ISMP Medication Safety Alert! Acute care edition. December 2, 2021;(24)1-4.

Insulin is a high-alert medication that requires extra attention to safely manage blood sugar levels in chronic or acutely ill patients. This alert highlights look-alike/sound-alike packaging, delayed medication reconciliation, and dietary monitoring gaps as threats to safe insulin administration in emergencies. Recommendations for improvement are provided for both general in-hospital, and post-discharge care.

Pointing fingers: verbosity of patient safety narratives is associated with attribution of blame.

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Ackerman RS, Patel SY, Costache M, et al. Anesthesiology News. November 21, 2021.

Blame is known to limit discussions of near-misses and failures, which negatively impacts learning and incident reduction. This article describes work to examine blameful context present in anesthesiology incident documentation, reducing its viability as a successful investigation record. Length of text was identified as an enabler of blameful orientation, and limitations as to word count were one strategy to minimize the use of punitive language.

Disrespectful behavior in healthcare: has it improved? Please take our survey!

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ISMP Medication Safety Alert! Acute care edition. September 9, 2021;26(18);1-5.

Disrespectful behavior is a persistent contributor to failures in medical care. This article summarizes influences that enable the acceptance and perpetuation of unprofessional behaviors and calls for data to assess its presence and impact in health care environments. The deadline for survey participation is now closed.

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