The PSNet Collection

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

Save to Library

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.

Automated dispensing cabinet overrides-an evaluation of necessity in a pediatric emergency department.

Save to Library

Paterson EP, Manning KB, Schmidt MD, et al. J Emerg Nurs. 2022;48:319-327.

Automated dispensing cabinets (ADCs) can reduce medication dispensing errors by requiring pharmacist verification. This study found that medication overrides (i.e., bypassing pharmacist review before administration) in one pediatric emergency department were frequently not due to an emergent situation requiring immediate medication administration and could have been avoided.

A learning health system agenda for organizational approaches to enhancing occupational well-being among clinicians.

Save to Library

Rotenstein LS, Melnick ER, Sinsky CA. JAMA. 2022;Epub May 12.

Clinician well-being is increasingly seen as a quality and safety issue. This commentary discusses how systemic efforts must be built to enhance occupational well-being among clinicians. This approach discussed should consider both human factors and organizational design strategies to reduce burnout, cognitive overload, process frustration, and technology use.

Applying requisite imagination to safeguard electronic health record transitions.

Save to Library

Sittig DF, Lakhani P, Singh H. J Am Med Inform Assoc. 2022;29:1014-1018.

Transitions from one electronic health record (EHR) system to another can increase the risk of patient safety events. Using the principles of requisite imagination, this article outlines six recommendations for safe EHR transitions through proactive approaches, process improvement and support for healthcare workers.

In Conversation With... Remle P. Crowe, PhD

Save to Library

May 16, 2022

Remle Crowe, PhD, NREMT, is the Director of Clinical and Operational Research at ESO. In her professional role, she provides strategic direction for the research mission of the organization, including oversight of a warehouse research data set of de-identified records (the ESO Data Collaborative). We spoke with her about how data is being used in the prehospital setting to improve patient safety.

Identifying Safety Events in the Prehospital Setting

Save to Library

May 16, 2022

This piece focuses on measuring and monitoring patient safety in the prehospital setting.

Check Twice, Transport Once

Save to Library

May 16, 2022

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

Presenting complaint: use of language that disempowers patients.

Save to Library

Cox C, Fritz Z. BMJ. 2022;377:e066720.

As more patients are gaining access to their electronic health records, including clinician notes, the language clinicians use can shape how patients feel about their health and healthcare provider. This commentary describes how some words and phrases routinely used in provider notes, such as “deny” or “non-compliant”, may inadvertently build distrust with the patient. The authors recommend medical students and providers reconsider their language to establish more trusting relationships with their patients.

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

Save to Library

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.

The potential for leveraging machine learning to filter medication alerts.

Save to Library

Liu S, Kawamoto K, Del Fiol G, et al. J Am Med Inform Assoc. 2022;29:891-899.

Alert fatigue contributes to task burden and can threaten patient safety. In this study, researchers at one academic medical center found that machine learning techniques could enable intelligent filtering of medication alerts and reduce alert volume by 54%.

Indicators for implementation outcome monitoring of reporting and learning systems in hospitals: an underestimated need for patient safety.

Save to Library

Kuske S, Willmeroth T, Schneider J, et al. BMJ Open Qual. 2022;11:e001741.

Comprehensive implementation of reporting and learning systems (RLS, also known as incident reporting systems) is important for its successful use as a patient safety improvement tool. This study aimed to develop a set of “implementation patient safety indicator(s) sets” to monitor the extent to which an RLS has been implemented in hospitals. Implementation outcomes include acceptability, adoption, appropriateness, implementation costs, feasibility, fidelity, penetration, and sustainability. Study participants rated acceptability and sustainability as most relevant to successful implementation.

Engaging patients in the use of real-time electronic clinical data to improve the safety and reliability of their own care.

Save to Library

Schnock KO, Roulier S, Butler J, et al. J Patient Saf. 2022;18:e407-e413.

Patient safety dashboards are used to communicate real-time patient data to appropriately augment care. This study found that higher usage of an electronic patient safety dashboard resulted in lower 30-day readmission rates among patients discharged from adult medicine units compared to lower usage groups.

Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room

Save to Library

April 27, 2022

This WebM&M describes an adverse event due to mislabeling or “syringe swap” in a preoperative patient. The commentary outlines several recommendations and safeguards to ensure that medications administration is safe.

Anatomy of a cyberattack: part 4: quality assurance and error reduction, billing and compliance, transition to uptime.

Save to Library

Frisch NK, Gibson PC, Stowman AM, et al. Am J Emerg Med. 2022;Epub Feb 21.

Electronic health records (EHR) can improve patient care and safety but are not without potential risks. A cyberattack led to a 25-day shutdown of a hospital’s EHR that necessitated a rapid shift to manual processes. This article outlines the laboratory service’s processes during the shutdown, including patient safety and error reduction, billing, and maintaining compliance with regulatory policies.

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

Save to Library

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.

Effectiveness and safety of pulse oximetry in remote patient monitoring of patients with COVID-19: a systematic review.

Save to Library

Alboksmaty A, Beaney T, Elkin S, et al. The Lancet Digital Health. 2022;4:e279-e289.

The COVID-19 pandemic led to a rapid transition of healthcare from in-person to remote and virtual care. This review assessed the safety and effectiveness of pulse oximetry in remote patient monitoring (RPM) of patients at home with COVID-19. Results show RPM was safe for patients in identifying risk of deterioration. However, it was not evident whether remote pulse oximetry was more effective than other virtual methods, such as virtual visits, monitoring consultations, or online or paper diaries.

Workarounds in electronic health record systems and the revised Sociotechnical Electronic Health Record Workaround Analysis Framework: scoping review.

Save to Library

Blijleven V, Hoxha F, Jaspers MWM. J Med Internet Res. 2022;24:e33046.

Electronic health record (EHR) workarounds arise when users bypass safety features to increase efficiency. This scoping review aimed to validate, refine, and enrich the Sociotechnical EHR Workaround Analysis (SEWA) framework. Multidisciplinary teams (e.g. leadership, providers, EHR developers) can now use the refined SEWA framework to identify, analyze and resolve unsafe workarounds, leading to improved quality and efficiency of care.

Error and cognitive bias in diagnostic radiology.

Save to Library

Tee QX, Nambiar M, Stuckey S. J Med Imaging Radiat Oncol. 2022;66:202-207.

Diagnostic errors in radiology can result in treatment delays and contribute to patient harm. This article provides an overview of the common cognitive biases encountered in diagnostic radiology that can contribute to diagnostic error, and strategies to avoid these biases, such as the use of a cognitive bias mitigation strategy checklist, peer feedback, promoting a just culture, and technology approaches including artificial intelligence (AI).

Inviting patients to identify diagnostic concerns through structured evaluation of their online visit notes.

Save to Library

Giardina TD, Choi DT, Upadhyay DK, et al. J Am Med Inform Assoc. 2022;Epub Mar 29.

Most patients can now access their provider visit notes via online portals and many have reported mistakes such as diagnostic errors or missed allergies. This study asked patients who may be “at-risk” for diagnostic error about perceived concerns in their visit notes. Patients were more likely to report having concerns if they did not trust their provider and did not have a good feeling about the visit. Soliciting patient concerns may be one way to improve transparency regarding diagnostic errors and trust in providers.

Top 10 Patient Safety Concerns 2022.

Save to Library

ECRI. Plymouth Meeting, PA. March 2022.

The global COVID-19 pandemic has exacerbated patient safety concerns. ECRI presents the top ten patient concerns for 2022, including staffing challenges, human factors in telehealth, and supply chain disruptions.

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users