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Zimolzak AJ, Singh H, Murphy DR, et al. BMJ Health Care Inform. 2022;29(1):e100565.

Patient safety algorithms developed through research must also be implemented into clinical practice. This article describes the process of translating an electronic health record-based algorithm for detecting missed follow-up of colorectal or lung cancer testing, from research into practice. All 12 test sites were able to successfully implement the trigger and identify appropriate cases.
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.
Hyvämäki P, Kääriäinen M, Tuomikoski A-M, et al. J Patient Saf. 2022;18:210-224.
Previous studies have demonstrated health information exchanges (HIE) can improve the quality and safety of care by improving diagnostic concordance and reducing medication errors. This review synthesizes physicians’ and nurses’ perspectives on patient safety related to use of HIE in interorganizational care transitions. Several advantages of and challenges with HIE are detailed.
Abraham J, Pfeifer E, Doering M, et al. Anesth Analg. 2021;132:1563-1575.
Intraoperative handoffs between anesthesiologists are frequently necessary but are not without risk. This systematic review of 14 studies of intraoperative handoffs and handoff tools found that use of handoff tools has a positive impact on patient safety. Additional research is needed around design and implementation of tools, particularly the use of electronic health records to record handoffs.  
Reeves JJ, Ayers JW, Longhurst CA. J Med Internet Res. 2021;23:e24785.
The COVID-19 pandemic has led to an extraordinary increase in the use of telehealth. This article discusses unintended consequences of telehealth and outlines guidance to assist health care providers in determining the appropriateness of a telehealth visit.
Nygaard AM, Selnes Haugdahl H, Støre Brinchmann B, et al. J Clin Nurs. 2020;29:3822-3834.
Handoffs are essential to communicating important information and preventing adverse patient care outcomes.  This qualitative study explored how information about ICU patients’ family members is included in handovers. Findings suggest that written documentation about the family is inadequate and poorly structured and there is a need for user-friendly handoff tools that include information on patients’ family members.
Dadlez NM, Adelman J, Bundy DG, et al. Ped Qual Saf. 2020;5:e299-e305.
Diagnostic errors, including missed diagnoses of adolescent depression, elevated blood pressure, and delayed response to abnormal lab results, are common in pediatric primary care. Building upon previous work, this study used root cause analyses to identify the failure points and contributing factors to these errors. Omitted process steps included failure to screen for adolescent depression, failure to recognize and act on abnormal blood pressure values, and failure to notify families of abnormal lab results. Factors contributing most commonly to these errors were patient volume, inadequate staffing, clinic environment, electronic and written communication, and provider knowledge.
Kattel S, Manning DM, Erwin PJ, et al. J Patient Saf. 2020;16.
Prior research has found poor communication between hospital-based and primary care physicians and has suggested that this may contribute to medical errors. This systematic review included 19 studies assessing the transfer of information at hospital discharge between hospital-based and primary care providers (PCPs), or evaluating interventions aimed at improving the timeliness and quality of discharge information. The review found that timely communication of discharge summaries was low, with 55% (median) transferred to PCPs within 48 hours and 85% (median) within 4-weeks; 8.5% of discharge summaries were never transferred. Discharge summaries nearly always contained patient demographics, admission/discharge dates and primary diagnoses, but less frequently included pending test results, diagnostic tests performed and discharge medications.
Lacson R, Healey MJ, Cochon LR, et al. J Am Coll Radiol. 2020;17:765-772.
Radiological exams are often ordered but go unscheduled, which can delay diagnoses and lead to other medical errors. In this retrospective study at one academic institution, the clinical necessity of 700 unscheduled radiologic examination orders (100 from each of seven different radiographic modalities) was examined. Study results indicate that, except for CT, obstetric ultrasound and fluoroscopy radiologic tests, the majority of unscheduled orders are clinically necessary and that 7% of all radiologic examination orders remain unscheduled a month or more after the order was placed.
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University of North Carolina. She also serves as the Program Director for the Emergency Medical Services (EMS) Fellowship and was past-president of the National Association of EMS Physicians. We spoke with her about her experience working in emergency medical systems and safety concerns particular to this field.
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.
Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.
Artis KA, Bordley J, Mohan V, et al. Crit Care Med. 2019;47:403-409.
Reporting complete patient information during clinical rounds is important for achieving an accurate diagnosis and informing clinical management. Prior research has shown that data is sometimes omitted or inaccurately communicated on rounds. This observational study compared patient data shared by trainees and medical students on ICU rounds to that contained within the electronic health record. Researchers analyzed photocopies of trainee and student notes as well as audio recordings of their oral presentations. For the 157 patient presentations included in the study, they found all contained data omissions and that other team members on rounds supplemented a minimal amount of data missing from student and trainee presentations. The authors recommend additional oversight and education of trainees with regard to data presented on rounds.
Khoong EC, Cherian R, Rivadeneira NA, et al. Health Aff (Millwood). 2018;37:1760-1769.
California's Medicaid pay-for-performance program requires safety-net health care systems to report and improve upon diverse ambulatory safety measures. Researchers found that participating safety-net hospitals struggled to report accurate data. Systems had more success improving metrics that placed patients at risk of life-threatening harm when compared to metrics that required longer term follow-up or patient engagement.
Guttman OT, Lazzara EH, Keebler JR, et al. J Patient Saf. 2021;17:e1465-e1471.
Communication errors in health care are a persistent challenge to patient safety. This commentary advocates for studying behavioral, cognitive, linguistic, environmental, and technological factors to help understand barriers to effective information exchange in health care. The authors suggest that approaches targeting each set of barriers be developed and embedded into learning activities to generate lasting improvements.

Health Aff (Millwood). 2018;37(11):1723-1908.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.
Pronovost P, Johns MME, Palmer S, et al, eds. Washington, DC: National Academy of Medicine; 2018. ISBN: 9781947103122.
Although health information technology was implemented to improve safety, it has resulted in unintended consequences such as clinician burnout and perpetuation of incorrect information. This publication explores the barriers to achieving the interoperability needed to build a robust digital infrastructure that will seamlessly and reliably share information across the complex system of health care. The report advocates for adjusting purchasing behaviors to focus less on the price and features of each product and to instead look for interoperable technologies. The report outlines five action priorities to guide leadership decision-making around procurement, including championing systemwide interoperability and identifying goals and requirements. A PSNet interview discussed potential consequences of the digitization of health care.
Sederstrom J.
Medication errors continue to be a worldwide patient safety challenge that requires both systems and individual practice strategies for improvement. This magazine article describes how pharmacists can address failures associated with processing, dosing, care transitions, and information sharing to prevent medication errors.