The PSNet Collection

Associations between safety outcomes and communication practices among pediatric nurses in the United States.

Gampetro PJ, Segvich JP, Hughes AM, et al. J Pediatr Nurs. 2021;63:20-27.

Communicating and reporting patient safety incidents relies on a robust safety culture wherein health care providers feel supported, not blamed, for errors. Using pediatric registered nurses’ responses from the 2016 and 2018 Hospital Survey on Patient Culture, researchers explored (1) associations between the communication of RNs within their teams and the frequency that they reported safety events; (2) associations between RNs’ communication within their health care teams and their perceptions of safety within the hospital unit; and (3) whether RNs’ communication had improved from 2016 to 2018.

What counts as a voiceable concern in decisions about speaking out in hospitals: A qualitative study.

Dixon-Woods M, Aveling EL, Campbell A, et al. J Health Serv Res Policy. 2022;Epub Jan 3.

A key aspect of patient safety culture is the perception that all team members should speak up about safety concerns. In this study of 165 frontline and senior leader participants, deciding to report a safety event (referred to as a “voiceable concern”) is influenced by four factors: certainty that something is wrong and is an occasion for voice; system versus conduct concerns, forgivability, and normalization. Organizational culture and context effect whether an incident is considered a voiceable concern.

Potentially inappropriate prescribing and its associations with health-related and system-related outcomes in hospitalised older adults: a systematic review and meta-analysis.

Mekonnen AB, Redley B, Courten B, et al. Br J Clin Pharmacol. 2021;87(11):4150-4172.

Potentially inappropriate prescribing in older adults can result in medication-related harm. This systematic review of 63 studies found that potentially inappropriate prescribing was significantly associated with several system-related and health-related outcomes for older adults, including mortality, readmissions, adverse drug events, and functional decline.

2022 Patient Safety Awareness Week.

Institute for Healthcare Improvement. March 13–19, 2022.

This website provides resources for promoting patient safety during Patient Safety Awareness Week. The annual observance is held in March.

Medication/Drug Errors

The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety improvement strategies, and resources for design.

Patient outcomes after opioid dose reduction among patients with chronic opioid therapy.

Hallvik SE, El Ibrahimi S, Johnston K, et al. Pain. 2022;163(1):83-90.

Opiates are a high-risk medication due to the potential for adverse events including misuse and overdose. This study examined whether dose reduction or discontinuation after high-dose chronic opioid therapy is associated with suicide, overdose, or other adverse events. In this cohort of Oregon Medicaid recipients, discontinuation increased the risk for suicide or opioid-related adverse events. Patients with stable or increasing doses had an increased risk of overdose.

Patient Safety.

Dean J, Subbe C, eds. Future Healthc J. 2021;8(3):e559-e618.

Full realization of the patient voice as a resource for safety is challenging. This special section provides global perspectives examining cultural, organizational, and system-focused opportunities to fully use patient knowledge in improvement initiatives.

Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis.

Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21(1):139.

Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.

Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review.

Lo L, Rotteau L, Shojania KG. BMJ Open. 2021;11(12):e055247.

Situation, Background, Assessment, Recommendation (SBAR) is a mnemonic technique used to avoid communication failures during handoffs. This systematic review found that fidelity with SBAR is highest in classroom settings, but that studies in clinical contexts either did not achieve sufficient improvements in fidelity or did not assess fidelity.

Encouraging patients to speak up about problems in cancer care.

Mazor KM, Kamineni A, Roblin DW, et al. J Patient Saf. 2021;17(8):e1278-e1284.

Patient engagement and encouraging speaking up can promote safety. This randomized study found that patients undergoing cancer treatment who were randomized to an active outreach program were significantly more likely to speak up and report healthcare concerns than patients in the control group.

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

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.

Next of kin involvement in regulatory investigations of adverse events that caused patient death: a process evaluation.

Wiig S, Haraldseid-Driftland C, Tvete Zachrisen R, et al. J Patient Saf. 2021;17(8):e1707-e1718.

Families and next of kin are important partners in patient safety. In two Norwegian counties, next of kin who had lost a family member due to an adverse event participated in in-person meetings with inspectors as part of the regulatory investigation. This study explored the experiences and perspectives of the next of kin (Part 1) and regulatory inspectors (Part 2) involved in this new approach to next-of-kin involvement in regulatory investigations. Despite being an emotionally challenging process, next of kin viewed participation in the regulatory investigation as a positive experience and believed that their contributions improved the investigation process.

Prevalence of potentially harmful multidrug interactions on medication lists of elderly ambulatory patients.

Anand TV, Wallace BK, Chase HS. BMC Geriatr. 2021;21(1):648.

Older adults, particularly those taking more than one medication, are at increased risk of adverse drug events (ADE). In this study of 6,545 older adult patients who were prescribed at least 3 medications, multidrug interactions (MDI) were identified in 1.3% of medication lists. Psychotropic medications were the most commonly involved medication class; the most common serious ADE were serotonin syndrome, seizures, prolonged QT interval, and bleeding.

Communicating certainty in pathology reports: interpretation differences among staff pathologists, clinicians, and residents in a multicenter study.

Gibson BA, McKinnon E, Bentley RC, et al. Arch Pathol Lab Med. 2021;Epub Oct 21.

A shared understanding of terminology is critical to providing appropriate treatment and care. This study assessed pathologist and clinician agreement of commonly-used phrases used to describe diagnostic uncertainty in surgical pathology reports. Phrases with the strongest agreement in meaning were “diagnostic of” and “consistent with”. “Suspicious for” and “compatible with” had the weakest agreement. Standardized diagnostic terms may improve communication.

The reduction of race and gender bias in clinical treatment recommendations using clinician peer networks in an experimental setting.

Centola D, Guilbeault D, Sarkar U, et al. Nature Commun. 2021;12(1):6585.

Race and gender bias in healthcare remains a public health problem. Study participants were assigned to a control (i.e., independent reflection) or intervention (i.e., “egalitarian” information exchange network) group and asked to provide diagnostic and treatment recommendations for standardized patients (a white man or a black woman). Participants in the intervention group were more likely to recommend appropriate care and showed no bias in final recommendations. The authors note that these findings indicate that clinician network interventions might be useful in healthcare settings to reduce disparities in patient treatment.

Reducing medication errors for adults in hospital settings.

Ciapponi A, Fernandez Nievas SE, Seijo M, et al. Cochrane Database Syst Rev. 2021;11(11):CD009985.

Medication errors can lead to harm in hospitalized patients including increased length of stay, lower quality of life, increased morbidity, and even death. This review of 65 studies and 110,875 patients examined interventions (primarily medication reconciliation) and their effect on reducing adverse drug events. Findings revealed mostly low to moderate certainty about the effectiveness of medication reconciliation and low certainty on other interventions, emphasizing the importance of research that has greater power and is methodologically sound.

Identifying safe care processes when GPs work in or alongside emergency departments: a realist evaluation.

Cooper A, Carson-Stevens A, Edwards M, et al. Br J Gen Pract. 2021;71(713):e931-e940.

In an effort to address increased patient demand and resulting patient safety concerns, England implemented a policy of general practitioners working in or alongside emergency departments. Thirteen hospitals using this service model were included in this study to explore care processes and patient safety concerns. Findings are grouped into three care processes: facilitating appropriate streaming decisions, supporting GPs’ clinical decision making, and improving communication between services.

The aspects of healthcare quality that are important to health professionals and patients: a qualitative study.

Hannawa AF, Wu AW, Kolyada A, et al. Patient Educ Couns. 2021;Epub Oct 30.

In this qualitative study, researchers explore physician, nurse, and patient perspectives about what features constitute “good” and “poor” care episodes. Participants highlighted the importance of quickly identifying and responding to errors and failures as one key component of good quality care.

Semantically ambiguous language in the teaching operating room.

Liu C, McKenzie A, Sutkin G. J Surg Edu. 2021;78(6):1938-1947.

Communication failures are a common cause of patient harm. This qualitative study found that potentially ambiguous language is common in surgical training settings. In addition to creating challenges for trainee comprehension of surgical instruction, ambiguous language can lead to miscommunications and near misses.

Input for the TeamSTEPPS Curriculum Updates.

Rockville MD, Agency for Healthcare Quality and Research. December 7, 2021.

The TeamSTEPPS program is an established approach for improving teamwork and communication in health care. This announcement calls for feedback from healthcare teams and team members on how to update the current TeamSTEPPS training curriculum. The deadline for submitting comments is January 10, 2022.

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