The PSNet Collection

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.

TeamSTEPPS Master Training Virtual Course.

AHA Team Training. January 26--March 30, 2022.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This online series will prepare participants to guide their organizations through implementation of the TeamSTEPPS program. It is designed for individuals that are new to TeamSTEPPS processes.

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.

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.

Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals.

McHugh MD, Aiken LH, Sloane DM, et al. The Lancet. 2021;397(10288):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.

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.

What are the implications for patient safety and experience of a major healthcare IT breakdown? A qualitative study.

Scantlebury A, Sheard L, Fedell C, et al. Digit Health. 2021;7:205520762110100.

Electronic health record (EHR) downtime can disrupt patient care and increase risk for medical errors. Semi-structured interviews with healthcare staff and leadership at one large hospital in England illustrate the negative consequences of a three-week downtime of an electronic pathology system on patient experience and safety. The authors propose recommendations for hospitals to consider when preparing for potential technology downtimes.

Interprofessional training and communication practices among clinicians in the postoperative ICU handoff.

Massa S, Wu J, Wang C, et al. Jt Comm J Qual Patient Saf. 2021;47(4):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.

Optimizing Health IT for Safe Integration of Behavioral Health and Primary Care.

Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2021.

Effective integration of health information systems supports decision making and treatment coordination across practice settings. This report examines how gaps in information sharing can affect behavioral health care. The authors discuss the potential for diagnostic improvement through information system connections between primary care and behavioral health programs.

From fable to reality at Parkland Hospital: the impact of evidence-based design strategies on patient safety, healing, and satisfaction in an adult inpatient environment.

Rich RK, Jimenez FE, Puumala SE, et al. HERD. 2020;14(3):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.

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.

Virtual urgent care quality and safety in the time of Coronavirus.

Smith SW, Tiu J, Caspers CG, et al. Jt Comm J Qual Patient Saf. 2021;47(2):86-98.

COVID-19 restrictions and patient concerns have expanded use of telehealth. This study found virtual urgent care services to be an effective strategy for patient care during the pandemic.

The Life and Death of Elizabeth Dixon: A Catalyst for Change.

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.

Lost in translation--silent reporting and electronic patient records in nursing handovers: an ethnographic study.

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.

The impact of the use of employee functional flexibility on patient safety.

Salvador RO, Gnanlet A, McDermott C. Personnel Rev. 2020;50(3):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.

Improving accuracy of handoff by implementing an electronic health record-generated tool: an improvement project in an academic neonatal intensive care unit.

Koo JK, Moyer L, Castello MA, et al. Pediatr Qual Saf. 2020;5(4):e329.

Children are highly vulnerable to safety risks associated with written handoffs. This article describes the impact of unit-wide implementation of a new handoff tool using electronic health record (EHR) auto-populated fields for pertinent neonatal intensive care unit (NICU) patient data. Handoff time remained the same, and the tool increased the accuracy of patient data included in handoffs and reduced the frequency of incorrect medications listing.

L.A.’s poorest patients endure long delays to see medical specialists. Some die waiting.

Dolan J, Mejia B. Los Angeles Times. September 30, 2020.

Socioeconomic conditions influence access to health care, and as a result, reduce its safety and reliability. This story describes how inequity can affect the care of disadvantaged patient populations and shares data on wait times for specialty care in Los Angeles County that contributed to costly diagnostic and treatment delays.

The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul.

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.

High-Performance Work Systems in Health Care Management: Parts 1-5.

Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.

In this continuing series, high-performance work practices are explored and defined through literature review, case analysis, and research. The authors summarize findings and discuss how best practices can influence quality, safety, and efficiency outcomes. Topics covered include speaking up, central line infection prevention, and business case development.

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