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.

The Consequences of Miscommunication Regarding a Possible Artifact

June 30, 2021

A 52-year-old man complaining of intermittent left shoulder pain for several years was diagnosed with a rotator cuff injury and underwent left shoulder surgery. The patient received a routine follow-up X-ray four months later.

Unwell Women: Misdiagnosis and Myth in a Man-Made World.

Cleghorn E. New York, NY: Dutton; 2021. ISBN: 9780593182956.

Women have been affected by implicit bias that undermines the safety of their care and trust in the medical system. This book shares the history anchoring the mindsets driving ineffective care for women and a discussion of the author’s long-term lupus misdiagnosis.

The “Great Pretender” (Syphilis) is Still Stumping Healthcare Providers

May 26, 2021

A healthy 53-year-old man presented for sexually transmitted infection (STI) screening after being informed by the health department that he had sexual intercourse with a male partner who was recently diagnosed with and treated for syphilis. He acknowledged having unprotected sex with male partners, reported no history of syphilis or Human Immunodeficiency Virus (HIV), and denied any penile lesions, discharge, or rash.

Improving handoff by deliberate cognitive processing: results from a randomized controlled experimental study.

van Heesch G, Frenkel J, Kollen W, et al. Jt Comm J Qual Patient Saf. 2020;47(4):234-241.

Poor handoff communication can threaten patient safety. In this study set in the Netherlands, pediatric residents were asked to develop a contingency plan for patients received during handoffs and asked to recall information from that handoff five hours later. Results indicate that engaging in deliberate cognitive processing during handoffs resulted in better understanding of patients’ problems, which could contribute to improved patient safety.

Assessing reasons for decreased primary care access for individuals on prescribed opioids: an audit study.

Lagisetty P, Macleod C, Thomas J, et al. Pain. 2021;162(5):1379-1386.

Inappropriate prescribing of opioids is a major contributor to the ongoing opioid epidemic. This study involved simulated patients with chronic opioid use who called primary care clinics in need of a new provider because their previous physician had retired or stopped prescribing opioids. Findings indicate that primary care providers were generally unwilling to prescribe opioids to patients whose histories are suggestive of misuse, which may raise access to care concerns and cause potential unintended harm for some patients.

Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri.

Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 5, 2021. Report No. 20-01521-48.

This investigation examined care coordination, screening and other factors that contributed to a patient death by suicide shortly after discharge from a Veteran’s Hospital. Event reporting, disclosure and evaluation gaps were identified as process weaknesses to be addressed.

TeamSTEPPS for the COVID-19 Crisis.

AHA Team Training.

The COVID-19 crisis requires cooperation and coordination of organizations and providers to address the persistent challenges presented by the pandemic. This on-demand video collection reinforces core TeamSTEPPS; methods that enhance clinician teamwork and communication skills to manage care safety during times of crisis.

Implementation of a parent-centered approach to the preinduction checklist in pediatric surgery.

Arshad SA, Ferguson DM, Garcia EI, et al. J Surg Res. 2021;257:455-461.

Engaging patients and families is an important strategy in ensuring safe health care delivery. In this prospective, observational study, use of a parent-centered script did not improve parent engagement during the preinduction checklist and resulted in an expected decline in checklist adherence.

Missed acute coronary syndrome during telephone triage at out-of-hours primary care: lessons from a case-control study.

Erkelens DC, Rutten FH, Wouters LT, et al. J Patient Saf. 2022;18(1):40-45.

Delays in diagnosis and treatment during after-hours care pose serious threats to patient safety. This case-control study compared missed acute coronary syndrome (ACS) cases to other cases with chest discomfort occurring during out-of-hours services in primary care. Predictors of missed ACS included the use of cardiovascular medication, non-retrosternal chest pain, and consultation of the supervising general practitioner.

Implicit bias in stroke care: a recurring old problem in the rising incidence of young stroke.

Bhat A, Mahajan V, Wolfe N. J Clin Neurosci. 2021;85(Mar):27-35.

Misdiagnosis, variation in treatment of stroke and gaps in secondary prevention in young patients can result in adverse outcomes. This article discusses the possible causes of implicit bias in stroke care in this population, the effects of bias on patient outcomes, and interventions to circumvent implicit bias.

Speaking up about patient-perceived serious visit note errors: patient and family experiences and recommendations.

Lam BD, Bourgeois FC, Dong ZJ, et al. J Am Med Inform Assoc. 2021;28(4):685-694.

Providing patients access to their medical records can improve patient engagement and error identification. A survey of patients and families found that about half of adult patients and pediatric families who perceived a serious mistake in their ambulatory care notes reported it, but identified several barriers to reporting (e.g. no clear reporting mechanism, lack of perceived support).

Delayed Breast Cancer Diagnosis: A False Sense of Security.

December 23, 2020

After a breast mass was identified by a physician assistant during a routine visit, a 60-year-old woman received a diagnostic mammogram and ultrasound. The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably benign” findings. When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred for a biopsy.

Omissions of care in nursing homes: a uniform definition for research and quality improvement.

Mangrum R, Stewart MD, Gifford DR, et al. J Am Med Dir Assoc. 2020;21(11):1587-1591.e2.

Building upon earlier work, the authors engaged a technical expert panel to reach consensus on a definition for omissions of care in nursing homes. The article details the terms and concepts included in (and excluded from) the proposed definition, provides examples of omissions of care, intended uses (e.g., to guide quality improvement activities or training and education), and describes the implications of the definition for clinical practice, policy, and research.

‘You’re going to release him when he was hurting himself?’

Dahlberg B. Kaiser Health News. September 29, 2020.

This story discusses failures related emergency psychiatric assessment, including premature discharge, implicit bias, patient management discontinuity and inappropriate physical restraint that contributed to the death of a patient at risk for suicide.

Doctors turned my sister away; less than two years later she died of cervical cancer.

Harvey-Jenner C. Cosmopolitan. August 27, 2020.

Implicit biases are known to impact effective diagnosis. This story highlights how dismissed concerns resulted in a delay in cancer diagnosis that contributed to the death of a young woman.

Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center.

Office of the Inspector General. Washington, DC: Department of Veterans Affairs; July 28, 2020. Report Number 19-07507-214.

Patient suicide is a never event. This report analyzes the death of a veteran after presenting at an emergency room with suicidal ideation. The analysis found lack of both suicide prevention policy adherence and appropriate assessment, as well as a lack concern for the patient’s condition contributed to the failure.

Hidden in plain sight — reconsidering the use of race correction in clinical algorithms.

Vyas DA, Eisenstein LG, Jones DS. N Engl J Med. 2020;383(9):874-882.

Physicians commonly use diagnostic algorithms and practice guidelines to individualize risk assessment and guide clinical decisions. The authors discuss the possible dangers of using race-adjusted algorithms due to their potential to lead to diagnostic errors and delays in care.

Public sector organizational failure: a study of collective denial in the UK national health service.

Hendy J, Tucker DA. J Bus Ethics. 2020;2021;172:691–706.

Using the events at the United Kingdom’s Mid Staffordshire Trust hospital as a case study, the authors discuss the impact of ‘collective denial’ on organizational processes and safety culture. The authors suggest that safeguards allowing for self-reflection and correction be implemented early in the safety reporting process, and that employees be granted power to speak up about safety concerns.

The nurse's experience of decision-making processes in missed nursing care: a qualitative study.

Abdelhadi N, Drach‐Zahavy A, Srulovici E. J Adv Nurs. 2020;Epub Apr 13.

This qualitative study conducted focus groups with 28 registered nurses working in different hospital settings to explore perspectives regarding decision-making and personal or contextual attributes leading to missed nursing care. Three themes emerged based on the analysis: missed nursing care can result due to scarce resources or nurses’ agency, differences in thinking based on routine or novel situations, and situational factors triggering fluctuations in their awareness (such as difficult patients or the presence of family). The authors suggest that organizational training programs should encourage nurses to identify barriers and facilitators of missed nursing care and approaches to overcome these factors.

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