The PSNet Collection

Maternal Safety

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Suicide and suicide attempts on hospital grounds and clinic areas.

Mills PD, Watts BV, Hemphill RR. J Patient Saf. 2021;17(5):e423-e428.

Researchers reviewed 15 years of root cause analysis reports of all instances of suicide and suicide attempts on Veterans Health Administration (VHA) grounds. Forty-seven suicides or suicide attempts were identified, and primary root causes included communication breakdown and a need for improved suicide interventions. The paper includes recommended actions to address the root causes of attempted and completed patient suicides.

Patient Safety Certificate Program.

American Society for Healthcare Risk Management. Henry B. Gonzalez Convention Center, San Antonio, TX; October 9-10 2021.

This onsite program will cover key patient safety concepts and how to apply them to improve safety. To help prepare attendees for designing and sustaining safety initiatives at their organizations, preconference activities will discuss safety culture, human factors, communication, and leadership development.

The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: the QUMwatch study.

Adie K, Fois RA, McLachlan AJ, et al. Br J Clin Pharmacol. 2021;Epub May 23.

Medication errors are a common cause of patient harm. This study analyzed medication incident (MI) reports from thirty community pharmacies in Australia. Most errors occurred during the prescribing stage and were the result of interrelated causes such as poor communication and not following procedures/guidelines. Further research into these causes could reduce medication errors in the community.

Critical care nurses’ physical and mental health, worksite wellness support, and medical errors.

Melnyk BM, Tan A, Hsieh AP, et al. Am J Crit Care. 2021;30.

This survey of 771 critical care nurses found that 40% had at least one symptom of depression and nearly half experienced some degree of anxiety. Nurses with poor physical or mental health reported making more medical errors than their healthier counterparts and nurses in supportive workplaces were more likely to have better physical and mental health. The authors suggest that improvements in an organization’s health and wellness support programs could result in fewer reported medical errors. Notably, this study was completed prior to the COVID-19 pandemic which has led to an even further decline in nurse wellness.

Reducing surgical specimen errors through multidisciplinary quality improvement.

Holstine JB, Samora JB. Jt Comm J Qual Patient Saf. 2021;47(9):563-571.

Errors in surgical specimen handling can cause treatment delays or missed diagnoses. This children’s hospital implemented a quality improvement effort to reduce surgical specimen errors. Using a variety of methods, including changes to specimen labeling, improved communication, and specimen time-out, they were able to decrease the mean rate of order errors and labeling-related errors.

Examining causes and prevention strategies of adverse events in deceased hospital patients: a retrospective patient record review study in the Netherlands.

Smits M, Langelaan M, de Groot J, et al. J Patient Saf. 2021;17(4):282-289.

This study used trained reviewers to examine root causes of adverse events in 571 deceased hospital patients in the Netherlands. Preventable adverse events were commonly caused by technical, organizational, and human causes; technical causes also commonly contributed to preventable deaths from adverse events. The authors discuss strategies to reduce adverse events, including improving communication and information structures, evaluating safety behaviors, and continuous monitoring of patient safety and quality data.

CANDOR Webinar Series.

Patient Safety Movement Foundation. 2021.

The Communication and Optimal Resolution (CANDOR) model was designed to support early error disclosure with patients and families after mistakes in care occur. This three-part webinar series introduced the CANDOR process, discussed CANDOR implementation, outlined the importance of organizational readiness assessment for the program, and described actions to sustain CANDOR after it has launched. Speakers include Dr. Timothy McDonald, the originator of the model.

Interprofessional and intraprofessional communication about older people's medications across transitions of care.

Manias E, Bucknall T, Woodward-Kron R, et al. Int J Environ Res Public Health. 2021;18(8):3925.

Interprofessional communication is critical to safe medication management during transitions of care. Researchers conducted this ethnographic study to explore inter- and intra-professional communications during older adults’ transitions of care. Communication was influenced by the transferring setting, receiving setting, and ‘real-time’ communication. Lack of, or poor, communication impacted medication safety; researchers recommend more proactive communication and involvement of the pharmacist.

Communication of preclinical emergency teams in critical situations: a nationwide study.

Zimmer M, Czarniecki DM, Sahm S. PLoS ONE. 2021;16(5):e0250932.

Inadequate team communication is a marker of poor safety culture and can threaten patient safety. This survey of 714 medical and non-medical emergency medical services (EMS) employees in Germany found nearly three-quarters of respondents had been involved in a patient harm incident and that deficits in team communication were a primary contributor.

I-PASS handover system: a decade of evidence demands action.

Shahian DM. BMJ Qual Saf. 2021;30(10):769-774.

The I-PASS structured handoff tool aims to improve communication during patient transfers and reduce errors and preventable adverse events. This editorial summarizes evidence supporting I-PASS implementation and the challenge of rigorously assessing the association between handoffs and adverse events, medical errors, and other clinical outcomes.

International Forum on Quality & Safety in Healthcare- Australasia

Institute for Healthcare Improvement, British Medical Journal. September 8-10, 2021.

This virtual conference will offer an introduction to quality and safety improvement success and challenges drawing from international experiences. Course activities designed for a multidisciplinary audience will cover topics such as value, improvement methods, and leadership.

Fatal mistakes: why do ten-fold medication errors in children keep happening?

Parry C. The Pharmaceutical Journal. April 22 2021.

Weight-based prescribing in children harbors challenges to accurate medication dosing. This story discusses an examination of factors contributing to ten-fold medication errors in pediatric care. The author summarizes an ongoing investigation which has identified polypharmacy and information system weaknesses as being among the contributors to the problem.

Enhancing patient safety by integrating ethical dimensions to critical incident reporting systems.

Wehkamp K, Kuhn E, Petzina R, et al. BMC Med Ethics. 2021;22(1):26.

Clinicians are often confronted by ethical issues during the delivery of care. The authors outline four categories of critical incidents relevant to biomedical ethics – (1) patient-related communication, (2) consent, autonomy, and patient interest, (3) conflicting economic and medical interests, and (4) staff communication and corporate culture. The authors suggest that integrating these dimensions into existing incident reporting system processes (e.g., training risk managers and nurses to identify ethical incidents, involving an ethnical committee or specialists for clinical ethical consultations) may increase ethical behavior, patient safety, and employee satisfaction.

A Sweet Case of Hidden Hydrogen Ions

April 28, 2021

A 24-year-old woman with type 1 diabetes presented to the emergency department with worsening abdominal pain, nausea, and vomiting. Her last dose of insulin was one day prior to presentation. She stopped taking insulin because she was not tolerating any oral intake. The admitting team managed her diabetes with subcutaneous insulin but thought the patient did not meet criteria for diabetic ketoacidosis (DKA), but after three inpatient days with persistent hyperglycemia, blurred vision, and altered mental status, a consulting endocrinologist diagnosed DKA.

Taking action to close the loop on diagnostic error: a Constellation and SIDM Collaborative.

Constellation, Society to Improve Diagnosis in Medicine.

The processes supporting safe and accurate diagnosis involve many steps that are prone to human error. This collaborative will engage teams to explore test result management and follow-up coordination to improve timeliness, collaboration, and communication to support safe care. The launch of the collaborative has been delayed due to COVID-19.

Leadership through crisis: fighting the fatigue pandemic in healthcare during COVID-19.

Whelehan DF, Algeo N, Brown DA. BMJ Leader. 2021;Epub Feb 22.

Healthcare workers are facing occupational fatigue stemming from the COVID-19 pandemic (e.g., burnout, stress) as well as fatigue related to ongoing symptoms of the virus (“long COVID”). This article discusses preventive and proactive leadership strategies to address both types of fatigue, including screening for fatigue, providing reasonable accommodations for healthcare workers struggling with fatigue, stress mediation, and establishing organizational culture supporting sleep and rest.

2022 Patient Safety Awareness Week.

Institute for Healthcare Improvement.

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

Approach to Improving Patient Safety: Communication

March 10, 2021

In this PSNet Annual Perspective, we review key findings related to improvement strategies when communicating with patients and different structured communication techniques to improve communication across providers. Lessons learned from innovative approaches explored under COVID-19 that could be considered as usual care resumes are also discussed.

The I-READI quality and safety framework: a health system’s response to airway complications in mechanically ventilated patients with Covid-19.

Ginestra JC, Atkins JH, Mikkelsen ME, et al. NEJM Catalyst. 2020;2(1).

Health systems are rapidly adjusting and adapting processes to successfully respond to the COVID-19 pandemic. The University of Pennsylvania Health System developed the I-READI (integration, root cause analysis, evidence review, adaptation, dissemination, and implementation) conceptual framework to assist hospitals in preparing for and responding to patient safety challenges during times of crisis, such as the COVID-19 pandemic. The I-READI approach can streamline communication, enrich collaboration, and coordinate rapid change through the use of daily safety huddles, root cause analysis, and technology (e.g., ICU telemedicine and real-time ICU dashboards).

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