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This Spotlight Case describes an older man incidentally diagnosed with prostate cancer, with metastases to the bone. He was seen in clinic one month after that discharge, without family present, and scheduled for outpatient biopsy. He showed up to the biopsy without adequate preparation and so it was rescheduled. He did not show up to the following four oncology appointments.

Dutra CK dos R, Guirardello E de B. J Adv Nurs. 2021;77:2398-2406.
This cross-sectional study describes the relationship between nurse work environment and missed nursing care, safety culture, and job satisfaction. Nurses who perceived a positive work environment reported reduced reasons for missed nursing care, an improved safety culture, and increased job satisfaction. Reasons for missed care were primarily related to lack of leadership support and resources. Nurse managers can increase perception of a positive work environment by providing additional support and adequate human and material resources.

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. 
Lam BD, Bourgeois FC, Dong ZJ, et al. J Am Med Inform Assoc. 2021;28:685-694.
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).  
Ferrara G, De Vincentiis L, Ambrosini-Spaltro A, et al. Am J Clin Pathol. 2021;155:64-68.
The COVID-19 pandemic has led to patients delaying or forgoing necessary health care.  Comparing the same 10-week period in 2018, 2019 and 2020, researchers used data from seven hospitals in northern-central Italy to assess the impact of COVID-19 on cancer diagnoses. Compared to prior years, cancer diagnoses overall fell by 45% in 2020. Researchers noted the largest decrease in cancer diagnoses among skin, colorectal, prostate, and bladder cancers.  

Washington, DC: Department of Veterans Affairs, Office of Inspector General; September 3, 2020. Report No 19-09493-249.

Discontinuities in mental health care are a patient safety concern. This report analyzes how documentation gaps, medication reconciliation problems, and poor care coordination contributed to the suicide of a patient who presented at an emergency room, was screened there, and referred to a clinic for further care that was not completed.
Waldman A, Kaplan J. ProPublica. 2020.
Hospitals have been deeply challenged to provide effective care during the COVID crisis. This article discusses how rationing and ineffective protection for families and patients may have contributed to preventable death and the spread of the virus in families due to unnecessary referrals of patients to home care and hospice.
Hafner K. New York Times. 2020;May 25.
The uncertainties surrounding coronavirus transmission and treatment are causing patients with known conditions to forgo needed medical care. This article outlines how COVID-19 fear and anxiety are primary contributing factors in patient decisions to delay transplants and other necessary treatments.
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.
A 63-year-old woman with hematemesis was admitted by a 2nd year medical resident for an endoscopy. The resident did not spend adequate time discussing her code status and subsequently, made a series of errors that failed to honor the patient’s preferences and could have resulted in an adverse outcome for this relatively healthy woman.
Simpkin AL, Murphy Z, Armstrong KA. Diagnosis (Berl). 2019;6:269-276.
Whether or not word selection during handoffs affects clinician anxiety and diagnostic uncertainty remains unknown. In this study involving medical students, researchers found that use of the word "hypothesis" compared to the word "diagnosis" when describing a hypothetical handoff from the emergency department to the inpatient setting was associated with increased self-reported anxiety due to uncertainty.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
Larson LA, Finley JL, Gross TL, et al. Jt Comm J Qual Patient Saf. 2019;45:74-80.
Workplace violence in the health care setting is common and poses an ongoing risk for providers and staff. The Joint Commission issued a sentinel event alert to raise awareness about the risks associated with physical and verbal violence against health care workers and suggests numerous strategies organizations can use to address the problem, including establishing reporting systems and developing quality improvement interventions. The authors describe a quality improvement initiative involving the development and iterative testing of a huddle handoff tool to optimize communication between the emergency department (ED) and an admitting unit regarding patients with the potential for violent behavior. The huddle tool led to improved perceptions of safety during the patient transfer process by both the ED nurses and the admitting medical units. An accompanying editorial highlights the importance of taking a systems approach to address workplace safety. A PSNet perspective explored how a medical center developed a process to identify, prioritize, and mitigate hazards in health care settings.
Dr. Krumholz is Professor of Medicine at the University of Yale School of Medicine and Director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation. We spoke with him about readmissions and post-hospital syndrome, a term he coined in an article in the New England Journal of Medicine to describe the risk of adverse health events in recently hospitalized patients.
Following elective lumbar drain placement to treat hydrocephalus and elevated intracranial pressures, a woman was admitted to the ICU for monitoring. After the patient participated in prescribed physical therapy on day 5, she complained of headaches, decreased appetite, and worsening visual problems—similar to her symptoms on admission. The nurse attributed the complaints to depression and took no action. Early in the morning, the patient was found barely arousable. The lumbar drain had dislodged, and a CT scan revealed the return of extensive hydrocephalus.
London, UK: Parliamentary and Health Service Ombudsman; 2017. ISBN: 9781528601344.
Patients with mental health conditions face particular safety challenges. This report describes incidents involving patients with eating disorders who experienced harm while receiving care in National Health Service organizations. Factors that contributed to the failures included poor care coordination, premature discharge, and lack of monitoring. The report discusses gaps in the investigations of these patient deaths and outlines areas of improvement.
Francis R. London, UK: Department of Health; February 2015.
Staff willingness to raise awareness of problems that could affect patient care is an important indicator of safety culture. This publication explores National Health Service (NHS) staff perceptions regarding raising concerns about health care safety. Barriers to speaking up were related to organizational culture, incident management, and legal protection for whistleblowers. The report also suggests measures for NHS organizations to use to help ensure that staff are comfortable raising awareness of patient safety concerns.
Patterson ME, Bogart MS, Starr KR. J Hosp Med. 2015;10:152-159.
Production pressure—the pressure to continue work at maximum capacity—is a known threat to patient safety. This study analyzed the effect of production pressures by examining the relationship between two components of safety culture. Using data from the 2010 AHRQ Hospital Survey on Patient Safety Culture, the investigators found that respondents at hospitals that worked in crisis mode more frequently also were more likely to perceive care transitions as unsafe. As emergency department overcrowding has also been linked to safety issues, the results of this study argue for efforts to manage bed capacity and patient flow as a patient safety strategy. A recent AHRQ WebM&M commentary explores how communication breakdowns and production pressure can cause adverse outcomes and highlights how checklists can help prevent mistakes.