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Millenson M. Forbes. September 16, 2022.

Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm was noted in the case discussed, the actions by the patient’s family to initiate an examination of the incident were rebuffed, patient disrespect was demonstrated, a near miss incident report was absent, and data omissions took place. The piece discusses how these detractors from safety were all present at the hospital involved.
Ramsey L, McHugh SK, Simms-Ellis R, et al. J Patient Saf. 2022;Epub Aug 2.
Patients and families can contribute unique insights into medical errors. This qualitative evidence review concluded that patients and families value involvement in patient safety incident investigations but highlight the importance of addressing the emotional aspects of care (e.g., timely apology, prioritizing trust and transparency). Healthcare staff perceived patient and family involvement in investigations to be important, but cited several barriers (e.g., staff turnover, fears of litigation) to effective investigations.

Clark C. MedPage Today. August 4. 

Consistent policy supporting transparency of hospital safety records is important for patients as they make provider choices. This article highlights a shift made to retain reporting requirements in the Hospital-Acquired Condition Reduction Program (HACRP) that had been threatened due to the influence of the COVID pandemic on data integrity.
Maher V, Cwiek M. Hosp Top. 2022;Epub Jul 20.
Fear of criminal liability may inhibit clinicians from reporting medical errors, thereby reducing opportunities for learning. This commentary discusses recent legal actions brought against clinicians, including Tennessee nurse RaDonda Vaught, and the negative impact such actions may have on the longstanding disclosure movement.
Ibrahim SA, Reynolds KA, Poon E, et al. BMJ. 2022;377:e063064.
Accreditation programs such as The Joint Commission are intended to improve patient safety and quality. Investigators evaluated the evidence base for 20 actionable standards issued by The Joint Commission. Standards were classified by the extent to which they were supported by evidence, evidence quality ratings, and the strength of the recommendation.
Wyner D, Wyner F, Brumbaugh D, et al. Pediatrics. 2021;148:e2021053091.
The dismissal of parental concerns is a known contributor to medical errors in children. This story illustrates how poor communication, lack of respect, and anchoring bias  contributed to failure in the care of a boy. The authors share actions being taken by the hospital involved in the tragedy to partner with the family to improve diagnosis practices throughout their organization.
Brenner MJ, Boothman RC, Rushton CH, et al. Otolaryngol Clin North Am. 2021;55:43-103.
This three-part series offers an in-depth look into the core values of honesty, transparency, and trust. Part 1, Promoting Professionalism, introduces interventions to increase provider professionalism. Part 2, Communication and Transparency, describes the commitment to honesty and transparency across the continuum of the patient-provider relationship. Part 3, Health Professional Wellness, describes the impact of harm on providers and offers recommendations for restoring wellness and joy in work.
Carrillo I, Mira JJ, Guilabert M, et al. J Patient Saf. 2021;17:e529-e533.
While prior research has shown patients want disclosure of adverse events, healthcare providers may still be hesitant to disclose and apologize. Factors that influence providers’ willingness to disclose errors and apologize include organizational support, experience in communicating errors, and expectations surrounding patient response. A culture of safety and a clear legal framework may increase providers’ willingness to disclose errors and apologize.

Ross NE, Newman WJ. J Am Acad Psychiatry Law. Epub 2021 May 21.

Open disclosure of errors and adverse events is increasingly encouraged in healthcare, but clinicians frequently cite fear of malpractice lawsuits as a reason to avoid apologizing for an error. This commentary summarizes the relationship between apologies and malpractice, the emergency of apology laws in the United States, and research exploring the impact of apology laws on malpractice claims and patient outcomes.

ISMP Medication Safety Alert! Acute Care Edition. October 8, 2020;25(20):1-4

In-depth investigations provide multidisciplinary insights that inform sustainable improvement opportunities. This newsletter story highlights a drug administration error examination by a dedicated office in the United Kingdom highlight the value of a commitment to deep, non-punitive analysis of patient safety incidents to enable transparency and learning.

Eng DM, Schweikart SJ. AMA J Ethics. 2020;22(9):e779-e783.

The recognition that humans err and the situation of response to error in a constructive and nonpunitive light are central to achieving safe patient care. This article discusses how implementation of just culture principles can assign accountability appropriately while encouraging disclosure and improvement when mistakes occur. 

Boston, MA: Institute for Healthcare Improvement: September 2020.  

This National Action Plan developed by the National Steering Committee for Patient Safety – a group of 27 national organizations convened by the Institute for Healthcare Improvement – provides direction for health care leaders and organizations to implement and adapt effective tactics and supportive actions to establish the recommendations laid out in the plan. Its areas of focus include culture, leadership, and governance, patient and family engagement, workforce safety and learning systems.  

Chicago, IL; Society to Improve Diagnosis in Medicine: August 2020. 

Patients and families provide unique insights for leaders working to improve diagnosis. This report highlights how organizations can best implement patient advisory council programs to spark learning, enhance feedback, and support a safety culture that enhances the impact of those efforts. 

Chicago, IL; Society to Improve Diagnosis in Medicine: August 2020.   

Patient and Family Advisory Councils (PFACs) are an established strategy that provides structure to a health care organization’s patient and family engagement efforts. This report shares insights and tools to establish a PFAC and engage them in diagnostic error reduction.      
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.
Arora S, Tsang F, Kekecs Z, et al. J Patient Saf. 2021;17:e1884-e1888.
An analysis of over 500 survey responses of healthcare professionals working in patient safety education in the United Kingdom explored facilitators and barriers to effective safety education. Interactive and experience-focused (e.g., simulations) learning were identified as ideal learning modalities; learning was most effective when combined with standardized methods and assessments, dedicated funding, and a culture encouraging transparency and speaking up. Common barriers to effective education cited by survey respondents included staffing and workload pressures, lack of accessibility (due to inconvenient timing, location or unavailable technology) and lack of awareness and buy-in for the importance of patient safety education.

Washington, DC: United States Government Accountability Office; March 2020. Publication GAO-20-248.

Maternal harm is a sentinel event precipitated by a confluence of factors. This report highlights US government and state-level efforts to reduce maternal mortality. Efforts funded through the programs include maternal morbidity review committees and safety bundle use initiatives.
Sattar R, Johnson J, Lawton R. Health Expect. 2020;23:571-583.
This systematic review used meta-ethnographic synthesis to explore patients’ and healthcare professionals’ views on, and experiences with, error disclosure. The 15 included studies highlighted a misalignment in attitudes and expectations between patients and healthcare professionals regarding error disclosure. While patients and family members emphasized the importance of disclosure with sincere regret and actions to prevent future errors, healthcare professionals cited several barriers to disclosure (e.g., blame culture, avoidance of litigation, lack of disclosure training and guidance).
Gandhi TK, Feeley D, Schummers D. NEJM Catalyst. 2020;1.
Health systems are encouraged to strive for zero preventable harm, but achieving this goal requires a comprehensive, systems-focused effort. This paper discusses the rationale for using ‘zero harm’ as a patient safety goal, and the importance of broadening the definition of harm to include non-physical harms (e.g., psychological harms), harms to caregivers and the healthcare workforce, and harms occurring beyond the hospital and across the care continuum. Four key elements required for successful systems change resulting in safety improvements are discussed: (1) change management, (2) culture of safety, (3) a learning system, and (4) patient engagement and codesign of healthcare.