The PSNet Collection

Mind the Implementation Gap. The Persistence of Avoidable Harm in the NHS.

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London UK: Patient Safety Learning: 2022.

Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financially. This report examines large system failures in the UK National Health Service to suggest actions that support learning and improvement. The publication highlights how public investigations, government reports, legal actions, and patient complaints can provide information to support the systems approach required to arrive at safe care.

The Media’s Role in Patient Safety

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April 27, 2022

This piece discusses the role that media plays in affecting patient safety.

Will prosecuting medical errors lead to a culture of silence?

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Fiore K. MedPage Today. March 28, 2022.

Experts are concerned that convictions for medical error have the potential to limit dialogue on the front line about medical mistakes. This article summarizes discussions regarding the verdict to convict a nurse due to a workaround that resulted in a medication error and patient death.

As a nurse faces prison for a deadly error, her colleagues worry: could I be next?

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Kelman B. Kaiser Health News. March 22, 2022

Criminalization of medical mistakes typifies the blame-focused approach patient safety leaders have worked to reduce in health care. This article covers a high-profile case of medication error involving an automated dispensing system that is ubiquitous in health care.

Medicare penalizes dozens of hospitals it also gives five stars.

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Rau J. Kaiser Health News. February 8, 2022.

Rating systems face challenges to accurately represent the safety and quality of patient care. This article discusses inconsistent results between national rating systems and those organizations penalized by the Hospital-Acquired Condition Reduction Program though reduction of Medicare payments for hospitals recording certain adverse events.

Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints.

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Washington, DC: United States Government Accountability Office; November 30, 2021. Publication GAO-22-105142.

Patient complaints have the potential to be used for care improvement as they surface problems in health facilities. This report examined complaint response processes in Veterans Affairs nursing homes and found them lacking. Five recommendations submitted to drive improvement underscore the value of adherence to policy and the transfer of complaint experiences to leadership.

Agency information collection activities: National Healthcare Safety Network (NHSN); comment request.

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Zirger JM, Centers for Disease Control and Prevention. Fed Register. September 27, 2021;86:53309-53312.

Tracking healthcare-associated infection (HAI) data aids in national, regional, and organizational design of HAI improvement efforts. This notice calls for public comment on the continuation of the National Healthcare Safety Network HAI information collection process. The comment period closes November 26, 2021.

Agency information collection activities: Nursing Home Survey on Patient Safety Culture Database; comment request.

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Agency for Healthcare Quality and Research. Fed Register. September 21, 2021;86:52471-52473.

This notice calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Nursing Home Survey on Patient Safety Culture Database data collection process. The comment period is closed.

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.

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Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.

Organizational assessments often provide insights that address overarching quality and safety challenges. This extensive inspection report shares findings from inspections of 36 Veterans Health Administration care facilities. Recommendations drawn from the analysis call for improvements in suicide death review, root cause analysis result application, and safety committee action item implementation.

Do black and white patients experience similar rates of adverse safety events at the same hospital?

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Gangopadhyaya A. Washington DC; Urban Institute: July 2021.

Racial inequities have been revealed by the COVID pandemic as a distinct patient safety concern. This report examined racial differences using patient safety indicators to measure hospital-acquired conditions, insurance coverage, and hospital patient population. The results indicate Black patients have reduced safety, that insurance coverage had little influence on safety and hospitals with a higher Black patient population experienced more adverse events that those serving a white patient population.

Recognizing Unsafe Care: What It Is and How to Report It.

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Patient Safety Foundation. August 26, 2021.

This webinar introduced medical error and harm as related concepts to identify unsafe care and enhance response, engagement, and reporting efforts of clinicians, patients and families.

Wrong Site Surgery–Wrong Tooth Extraction.

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Farnborough, UK: Healthcare Safety Investigation Branch; April 22, 2021.

Wrong-site surgery in dentistry is a frequent and persistent never event. This report examines a case of pediatric wrong tooth extraction to reveal how the application of safety standards is influenced by the work environment and discusses the use of forcing functions to create barriers to error in practice.

Veterans Accountability Improvement Act.

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SB 1307, 117th Congress: 2021.

Reporting clinicians who exhibit practice behaviors that are detrimental to safety is challenged by system and cultural norms. This legislation aims to strengthen the US Veterans Health System process for identifying problematic clinicians by underscoring the importance of reporting to a national system that tracks these instances.

In U.S. nursing homes, where Covid-19 killed scores, even reports of maggots and rape don’t dock five-star ratings.

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Silver-Greenberg J, Gebeloff R. New York Times. March 13, 2021.

The value of rating systems can be challenged by bias and misinterpretation due to a variety of factors. This article outlines how nursing home patients fell victim to both systemic and care failings in the US nursing homes, yet their facilities still ranked high in a national rating system. The authors discuss failures including the lack of data auditing and a focus on ratings rather than quality.

A woman’s laborious search uncovered the probable cause of her searing abdominal pain. Getting a doctor to help was much harder.

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Boodman SG. Washington Post. February 20, 2021.

Difficult diagnostic journeys are compounded by lack of clinician empathy, bias awareness, and critical thinking. This piece shares the story of a patient whose efforts to identify the cause of her pain were hampered by heuristics, premature closure, and poor patient relationship building.

Harmed Patient Alliance.

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United Kingdom.

Patients and families that experience medical harm have unique support needs. This organization works to improve health system and clinician response to harmed patients. Their efforts aim to create a deeper understanding of the factors contributing to lack of response to concerns to enhance existing processes.

Using Twitter to assess patient takes on patient experience.

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Heath S. Patient Engagement HIT. October 29, 2020.

Twitter is evolving as a useful data source for patient safety. This news story discusses an examination of public use of a patient-complaint hashtag that recorded patient experiences of misdiagnosis, disrespect and miscommunication that contributed to poor relations with physicians, medical errors, and harm.

Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke.

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Farnborough, UK; Healthcare Safety Investigation Branch. October 13, 2020

Errors of omission in routine care can result in patient harm. This report discusses factors contributing to a pulmonary embolism in a recovering stroke patient acerbated by a lack of intended but omitted venous thromboembolism or VTE preventative care. The system improvement recommendations drawn from the incident analysis include that the UK National Health Service develop a standardized approach to VTE risk assessment and broad-based training to enable a cross-section of clinicians to use VTE prevention devices as required.

Investigation into the Role of Clinical Pharmacy Services in Helping to Identify and Reduce High-risk Prescribing Errors in Hospital.

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Farnborough, UK: Healthcare Safety Investigation Branch; September 24, 2020.

Unit-based pharmacy services help to mitigate and catch medication errors. This report highlights a case of a medication error death and describes how embedding clinical pharmacy services could have prevented this incident. The report provides system level recommendations to enhance this service including defining the role of clinical pharmacy teams and prioritizing the tactic as an important improvement strategy.

Some health workers suffering from addiction steal drugs meant for patients.

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Mann B. All Things Considered. National Public Radio. October 5, 2020.

Clinicians are susceptible for medication misuse due to stress, fatigue, or arrogance. This news article discusses how drug diversion should signal behaviors that can harm patients, the clinicians themselves, and the organizations they work for. Reporting gaps contribute to the perpetuation of the problem.

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