The PSNet Collection: All Content
Search All Content
- Journal Article(765)
- Newspaper/Magazine Article(54)
- Patient Safety Innovations(2)
- Patient Safety Primers(3)
- Perspectives on Safety(25)
- Press Release/Announcement(2)
- Special or Theme Issue(22)
- WebM&M Cases(160)
- Web Resource(39)
- Care Coordination(10)
- Communication Improvement(737)
- Computerized Decision Support(17)
- Computerized Provider Order Entry (CPOE)(21)
- Culture of Safety(60)
- Education and Training(189)
- Error Reporting and Analysis(153)
- Human Factors Engineering(118)
- Legal and Policy Approaches(44)
- Logistical Approaches(142)
- Policies and Operations(10)
- Quality Improvement Strategies(196)
- Research Directions(5)
- Specialization of Care(77)
- Technologic Approaches(195)
- Transparency and Accountability(4)
- Alert fatigue(5)
- Device-Related Complications(51)
- Diagnostic Errors(136)
- Discontinuities, Gaps, and Hand-Off Problems(1105)
- Drug shortages(1)
- Failure to rescue(6)
- Fatigue and Sleep Deprivation(29)
- Identification Errors(61)
- Inpatient suicide(1)
- Interruptions and distractions(29)
- Medical Complications(108)
- Medication Safety(259)
- Nonsurgical Procedural Complications(12)
- Psychological and Social Complications(47)
- Second victims(2)
- Surgical Complications(73)
- Transfusion Complications(1)
- Transitions of Care(8)
A 72-year-old man was diagnosed with COVID-19 pneumonia and ileus, and admitted to a specialized COVID care unit. A nasogastric tube (NGT) was placed, supplemental oxygen was provided, and oral feedings were withheld. Early in his hospital stay, the patient developed hyperactive delirium and pulled out his NGT. Haloperidol was ordered for use as needed (“prn”) and the nurse was asked to replace the NGT and confirm placement by X-ray. The bedside and charge nurses had difficulty placing the NGT and the X-ray confirmation was not done.
Järvinen TLN, Rickert J, Lee MJ, et al. Clin Orthop Relat Res. 2013-2023.
Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS is a Medical Officer in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality. Dr. Deutsch is a pediatric otolaryngologist and has vast experience in simulation and resilience engineering. We spoke with her about resilient healthcare and how resilient engineering principles are applied to improve patient safety.
This piece discusses resilient healthcare and the Safety-I and Safety-II approaches to patient safety.
Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system.
Dr. Pascale Carayon, PhD, is a professor emerita in the Department of Industrial and Systems Engineering and the founding director of the Wisconsin Institute for Healthcare Systems Engineering (WIHSE). Dr. Nicole Werner, PhD, is an associate professor in the Department of Health and Wellness Design at the Indiana University School of Public Health-Bloomington. We spoke with both of them about the role of human factors engineering has in improving healthcare delivery and its role in patient safety.
A 61-year-old women with a mechanical aortic valve on chronic warfarin therapy was referred to the emergency department (ED) for urgent computed tomography (CT) imaging of the right leg to rule out an arterial clot. CT imaging revealed two arterial thromboses the right lower extremity and an echocardiogram revealed a thrombus near the prosthetic heart valve. The attending physician ordered discontinuation of warfarin and initiation of a heparin drip.
A 47-year-old man underwent a navigational bronchoscopy with transbronchial biospy under general anesthesia without complications. The patient was transferred to the post-acute care unit (PACU) for observation and a routine post-procedure chest x-ray (CXR). After the CXR was taken, the attending physician spoke to the patient and discussed his impressions, although he had not yet seen the CXR. He left the PACU without communicating with the bedside nurse, who was caring for other patients. The patient informed the nurse that the attending physician had no concerns.
Special thanks to Freya Spielberg, MD, MPH, Founder and CEO of Urgent Wellness LLC in Washington, DC; and Jack Westfall, MD, MPH, Director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, for their thoughtful interviews on the topic of Primary Care and Patient Safety, which helped lay the groundwork for this Perspective.
This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.
Freya Spielberg MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social enterprise dedicated to improving the health of Individuals living in low-income housing in Washington, DC.