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Webster KLW, Keebler JR, Lazzara EH, et al. Jt Comm Qual Patient Saf. 2022;48:343-353.
Effective handoff communication is a key indicator of safe patient care. These authors outline a new model for handoff communication, integrating three theoretical frameworks addressing relevant inputs (i.e., individual organizational, environmental factors), mediators (e.g., communication, leadership), outcomes (e.g., patient, provider, teamwork, and organizational outcomes), and adaptation loops.
Buitrago I, Seidl KL, Gingold DB, et al. J Healthc Qual. 2022;44:169-177.
Reducing hospital 30-day readmissions is seen as a way to improve safety and reduce costs. Baltimore City mobile integrated health and community paramedicine (MIH-CP) was designed to improve transitional care from hospital to home. After one year in operation, MIH-CP performed a chart review to determine causes of readmission among patients in the program. Root cause analysis indicated that at least one social determinant of health (e.g., health literacy) played a role in preventable readmissions; the program was modified to improve transitional care.
Lafferty M, Harrod M, Krein SL, et al. J Am Med Inform Assoc. 2021;28:28(12).
Use of one-way communication technologies, such as pagers, in hospitals have led to workarounds to improve communication. Through observation, shadowing, interviews, and focus groups with nurses and physicians, this study describes antecedents, types, and effects of workarounds and their potential impact on patient safety.
McHugh MD, Aiken LH, Sloane DM, et al. The Lancet. 2021;397:1905-1913.
While research shows that better nurse staffing ratios are associated with improved patient outcomes, policies setting minimum nurse-to-patient ratios in hospitals are rarely implemented. In 2016, select Queensland (Australia) hospitals implemented minimum nurse staffing ratios. Compared to hospitals that did not implement minimum nurse staffing ratios, length of stay, mortality, and readmission rates were significantly lower in intervention hospitals, providing evidence, once again, that minimum staffing ratios can improve patient outcomes. 

The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.

Massa S, Wu J, Wang C, et al. Jt Comm J Qual Patient Saf. 2021;47:242-249.
The objective of this mixed methods study was to characterize training, practices, and preferences in interprofessional handoffs from the operating room to the intensive care unit (OR-to-ICU). Anesthesia residents, registered nurses, and advanced practice providers indicated that they had not received enough preparation for OR-to-ICU handoffs in their clinical education or on-the-job training. Clinicians from all professions noted a high value of interprofessional education in OR-to-ICU handoffs, especially during early degree programs would be beneficial.
Rich RK, Jimenez FE, Puumala SE, et al. HERD. 2020;14:65-82.
Design changes in health care settings can improve patient safety. In this single-site study, researchers found that new hospital design elements (single patient acuity-adaptable rooms, decentralized nursing stations, access to nature, etc.) improved patient satisfaction but did not impact patient outcomes such as length, falls, medication events, or healthcare-associated infections.  

Kirkup B. London, England: Crown Copyright; 2020. ISBN 9781528622714.

Missed diagnosis of a dangerous condition in utero, treatment errors, lack of response to concerns raised, and inadequate clinician expertise were among the contributing factors identified in this analysis of the death of a special needs infant at home. The 12 recommendations stemming from the investigation include improvements in disclosure support, clinician communication across facilities, and assignment of accountability when false and misleading statements are made during investigations.
Ihlebæk HM. Int J Nurs Stud. 2020;109:103636.
Using ethnographic methods, this study explored the impact of ‘silent report’ (computer-mediated handover) on nurses’ cognitive work and communication. The authors summarize four emerging themes, which highlight and characterize the importance of oral communication to ensure accurate and useful handovers.
Salvador RO, Gnanlet A, McDermott C. Personnel Rev. 2020;50:971-984.
Prior research suggests that functional flexibility has benefits in several industries but may carry patient safety risks in healthcare settings. Using data from a national nursing database, this study examined the effect of unit-level nursing functional flexibility on the incidence of hospital-acquired pressure ulcers. Results indicate that higher use of functionally flexible nurses was associated with a higher number of pressure ulcers, but this effect was moderated when coworker support within the unit was high.

de Bienassis K, Llena-Nozal A, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 121.

Adverse events in long term care facilities are acerbated due to staffing, training and financial challenges. This report examined the costs of avoidable problems in long term care and suggests prevention strategies that center on workforce skill development and safety culture improvement.

Levett-Jones T, ed. Clin Sim Nurs. 2020;44(1):1-78; 2020;45(1):1-60.

Simulation is a recognized technique to educate and plan to improve care processes and safety. This pair of special issues highlights the use of simulation in nursing and its value in work such as communication enhancement, minority population care, and patient deterioration.   
Diaz MCG, Dawson K. Am J Med Qual. 2020;35:474-478.
Communication and shared mental models are key elements to effective teamwork. This study explored whether simulation-based closed-loop communication training would improve staff perceptions of communication ability and decrease medical errors. Increases in perception of closed-loop communication ability were sustained one-month after training. A retrospective chart review of all emergency severity index (ESI) level 1 patients (n=9) seen in the 4-months pre- and post-training showed a reduction in medical errors (89% to 56%, respectively).
Blease CR, Fernandez L, Bell SK, et al. BMJ Qual Saf. 2020;29:864–868.
Providing patients – particularly elderly, less educated, non-white, and non-English speaking patients – with access to their medical records via ‘open notes’ can improve engagement in care; however, these demographic groups are also less likely to take advantage of these e-tools. The authors summarize the preliminary evidence and propose steps to increasing use of open note portals among disadvantaged patients.
Kannampallil T, Abraham J. J Am Med Inform Assoc. 2020.
Prior research has found that many clinicians do not engage in active listening behaviors essential to safe patient care. This prospective observational study used a mixed-methods approach to better understand listening and question-asking behaviors during residents and nurses handoffs. The researchers did not identify any significant differences between residents and nurses in their active or passive listening behaviors, but they did find that nurses asked significantly more questions than residents.

Linnane R, Diedrich J. Milwaukee Journal Sentinel. February 25, 2020.

Delays in emergency room (ER) triage and assessment contribute to wide range of failures that degrade patient safety. This news story highlights the findings of a government report highlighting overcrowding and production pressures as factors resulting in the death of a patient waiting for care who initially presented at the ER with symptoms of heart attack.
Manges K, Groves PS, Farag A, et al. BMJ Qual Saf. 2020;29:499-508.
Teamwork Shared Mental Models (SMM) reflect the teams’ understanding of its members’ roles and interactions. This mixed-methods study examined teamwork-SMMs during discharge and described the differences of discharge teams with higher versus lower teamwork-SMMs. Teams with better teamwork-SMMs during discharge were more likely to report similar understanding of the patient’s situation, open communication and exchange of information, and team cohesion and resulted in more effective care delivery. Poor team-SMMs were characterized by divergent opinions regarding patient care plans, delays or gaps in communication, and team members operating independently and in isolation from their team.
A 62-year-old man with a history of malnutrition-related encephalopathy was admitted for possible aspiration pneumonia complicated by empyema and coagulopathy. During the hospitalization, he was uncooperative and exhibited signs of delirium. For a variety of reasons, he spent two weeks in the hospital with minimal oral intake and without receiving most of his oral medications, putting him at risk for complications and adverse outcomes.
Skaret MM, Weaver TD, Humes RJ, et al. J Healthc Qual. 2019;41:274-280.
I-PASS, a care transition handoff tool that enhances communication when coordinating patient transfer of care during medical shift changes, has been found to reduce preventable errors associated with handoffs. New pilot study found user-generated patient information and automatically compiled EHR data in the I-PASS format can reduce documentation errors.