The PSNet Collection

A simulation systems testing program using HFMEA methodology can effectively identify and mitigate latent safety threats for a new on-site helipad.

Holmes J, Chipman M, Barbour T, et al. Jt Comm J Qual Patient Saf. 2022;48(1):12-24.

Air medical transport carries unique patient safety risks. In this study, researchers used simulation training and healthcare failure mode and effect analysis (HFMEA) to identify latent safety threats related to patient transport via helicopter. This approach identified 31 latent safety threats (18 were deemed critical) related to care coordination, facilities, equipment, and devices.

TeamSTEPPS Master Trainer Course.

AHA Training. March 6-7, 2021. Hyatt Regency Chicago, Chicago, IL.

This education program will present group-focused opportunities for participants to learn how to apply Agency for Healthcare Quality and Research TeamSTEPPS 2.0 curriculum methods to develop staff training and improve team communication in their organizations.

Staffing, teamwork and scope of practice: analysis of the association with patient safety in the context of rehabilitation.

Jomaa C, Dubois C‐A, Caron I, et al. J Adv Nurs. 2021;Epub Nov 30.

Nurses play a critical role in ensuring patient safety. This study explored the association between the organization of nursing services and patient safety incidents in rehabilitation units. Findings highlight the key role of appropriate nurse staffing in reducing the incidence of events such as falls and medication errors

Disparities after discharge: the association of limited English proficiency and postdischarge patient-reported issues.

Malevanchik L, Wheeler M, Gagliardi K, et al. Jt Comm J Qual Patient Saf. 2021;47(12):775-782.

Communication in healthcare is essential but can be complicated, particularly when there are language barriers between providers and patients. This study evaluated a hospital-wide care transitions program, with a goal of universal contact with discharged patients to identify and address care transition problems. Researchers found that the program reached most patients regardless of English proficiency, but that patients with limited English proficiency experienced more post-discharge issues, such as difficulty understanding discharge instructions, medication concerns and follow-up questions, and new or worsening symptoms.

Examining the meaning of the language used to communicate the nursing hand-off.

Galatzan BJ, Carrington JM. Res Nurs Health. 2021;44(5):833-843.

During handoffs, nurses are exposed to a variety of interruptions and distractions which may lead to cognitive overload. Using natural language processing, researchers analyzed ten audio-recorded change of shift handoffs to estimate the cognitive load experienced by nurses. Nurses’ use of concise language has the potential to decrease cognitive overload and improve patient outcomes.

Influence of perioperative handoffs on complications and outcomes.

Burden AR, Potestio C, Pukenas E. Adv Anesth. 2021;39:133-148.

Handoffs occur several times during a perioperative encounter, increasing the risk of communication errors. Structured handoffs, such as situation-background-assessment-recommendation (SBAR) and checklists, have been shown to improve communication between providers during anesthesia care. The authors discuss how these tools and other processes can improve shared understanding of effective handoffs.

It's like sending a message in a bottle: a qualitative study of the consequences of one-way communication technologies in hospitals.

Lafferty M, Harrod M, Krein SL, et al. J Am Med Inform Assoc. 2021;28(12):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.

Hospital discharge and readmission.

Alper E, O'Malley TA, Greenwald J. UpToDate. September 20, 2021.

This review examines hospital discharge, details elements of the process that can increase risk of readmission, and reveals interventions to improve safety.

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.

Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS.

London, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016.

Lack of appropriate follow up of diagnostic imaging can result in care delays, patient harm, and death. This report summarizes an investigation of 25 imaging failures in the British National Health Service (NHS). The analysis identified communication and coordination issues resulting in lack of action and reporting of unanticipated findings to properly advance care. Recommendations to improve imaging in the NHS include use of previous analyses to enhance learning from failure.

The standardisation of handoffs in a large academic paediatric emergency department using I-PASS.

Chladek MS, Doughty C, Patel B, et al. BMJ Open Qual. 2021;10(3):e001254.

The I-PASS handoff bundle has been successful at improving patient safety during handoffs in the hospital. A pediatric emergency department implemented the I-PASS bundle to improve handoffs between medical residents. Results showed a 53% decrease in omissions of crucial information and residents perceived improvement in patient safety.

Missed nursing care during the COVID-19 pandemic: a comparative observational study.

von Vogelsang A‐C, Göransson KE, Falk A‐C, et al. J Nurs Manag. 2021;29(8):2343-2352.

Incomplete nursing care can be detrimental to care quality and patient safety. This cross-sectional survey of nurses in Sweden at one acute care hospital did not identify significant differences in missed nursing care before and during the COVID-19 pandemic. The authors posit that these results may be attributed to maintaining nurse-patient ratios, sufficient nursing skill mix, and patient mix.

Disparate perspectives: exploring healthcare professionals' misaligned mental models of older adults' transitions of care between the emergency department and skilled nursing facility.

Werner NE, Rutkowski RA, Krause S, et al. Appl Ergon. 2021;96:103509.

Shared mental models contribute to effective team collaboration and communication. Based on interviews and thematic analysis, the authors explored mental models between the emergency department (ED) and skilled nursing facility (SNF). The authors found that these healthcare professionals had misaligned mental models regarding communication during care transitions and healthcare setting capability, and that these misalignments led to consequences for patients, professionals, and the organization.

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.

An observational study of postoperative handoff standardization failures.

Abraham J, Meng A, Sona C, et al. Int J Med Inform. 2021;151:104458.

Standardized handoff protocols from the operating room to the intensive care unit have improved patient safety, but clinician compliance and long-term sustainability remain poor. This study identified four phases of post-operative handoff associated with risk factors: pre-transfer preparation, transfer and set up, report preparation and delivery, and post-transfer care. The authors recommend “flexibly standardized” handoff intervention tools for safe transfer from operating room to intensive care.

The perfect storm: exam of a medical error and factors contributing to its possible escalation.

Walters GK. J Patient Saf. 2021;17(4):e264-e267.

The majority of preventable adverse events are multifactorial in nature and are a result of system failures. Using a case study, the authors outline a series of errors following misplacement of a PICC line. Failures include differences in recording electronic health record notes and communication between providers. Investigations of all adverse events will help identify and correct system failures to improve patient safety.

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.

Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staff.

Carman E-M, Fray M, Waterson P. Appl Ergon. 2021;93:103339.

This study analyzed incident reports, discharge planning meetings, and focus groups with hospital and community healthcare staff to identify barriers and facilitators to safe transitions from hospital to community. Barriers included discharge tasks not being complete, missing or inaccurate information, and limited staff capacity. Facilitators include improved staff capacity and good communication between hospital staff, community healthcare staff, and family members. The authors recommend that hospital and community healthcare staff perspectives be taken into account when designing safe discharge policies.

Project BOOST Increases Patient Understanding of Treatment and Follow-up Care

May 26, 2021

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. Based on the success of this test, Patient Safe-D was incorporated as part of the Society of Hospital Medicine's Project BOOST (Better Outcomes for Older Adults through Safe Transitions) initiative which uses medication reconciliation, teach back and the Discharge Patient Education Tool (DPET) to help reduce medication-related errors. BOOST provides a full implementation toolkit to help institutions implement this and other programs to improve discharge education.

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.

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