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.

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

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Washington, DC: VA Office of Inspector General; March 17, 2022.

Electronic health record (EHR) implementation failures cause major disruptions to care delivery that can result in inefficiencies, misinformation, and unsafe care. This three-part investigation examines the impact of the new United States Veterans Affairs EHR system problems on medication management, care coordination, and problem reporting and resolution at one facility.

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.

The Safety of Maternity Services in England.

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Fourth Report of Session 2021–22. House of Commons Health Committee. London, England: The Stationery Office; July 6, 2021. Publication HC 19.

High-profile failures motivate examination and change of existing services. This report builds on maternity care failures in National Health Service trusts to recommend needed changes in learning from failure to effectively support clinicians providing maternity care, provide patient-centered care to mothers and babies, and learn from untoward incidents to enhance care safety.

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.

'An ongoing nightmare': people with obesity face major obstacles when seeking medical care.

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Schapiro R. NBC News. June 27, 2021.

System failures cause care delays in a wide range of patient segments. This news story describes barriers to safe, patient-centered care experienced by overweight patients such as bias, ineffective space consideration, and lack of access to screening equipment.

Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic.

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Washington, DC: Department of Veterans Affairs, Office of Inspector General. June 24, 2021. Report No. 19-09808-171.

This report examined veterans' health clinic use of telemental health to identify safety challenges inherent in this approach before the expansion of telemedine during the COVID-19 crisis. The authors note the complexities in managing emergent mental health situations in virtual consultations. Recommendations for improvement included emergency preparedness planning, specific reporting of telemental health incidents and organized access to experts.

Pandemic imperiled non-English speakers more than others.

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Bebinger M. WBUR and Kaiser Health News. April 27, 2021.

Non-English-speaking patients experience barriers to safely navigating the American healthcare system. This story discusses the impact that language and disparities had on care during the pandemic at one health system, and shares outreach communication and translation strategies to improve care safety.

When COVID-19 hit, many elderly were left to die.

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Stevis-Gridneff M, Apuzzo M, Pronczuk M. New York Times. 2020;August 8.

Residential care facilities have been challenged by COVID-19. This story examines the weakness of care processes in nursing homes in Europe that have been revealed due to the pandemic. Data gaps, resource allocation choices, and hospital space considerations are noted situations that have resulted in unintended consequences, reducing the safety of care for this at-risk population.

‘Last responders’ seek to expand postmortem COVID testing In unexplained deaths.

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Andrews M. Kaiser News Network. May 19, 2020.

Post-mortem examination is an important tool for determining if misdiagnosis occurs. The authors discuss the value of assessing cause of death for patients thought to have died from COVID-19 to understand disease spread and true impact.

Patient Safety Movement Foundation.

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This organization shares best practices to align and optimize efforts toward eliminating patient harm by the year 2030. The Foundation supports several awareness initiatives to drive improvements associated with its strategic aims that include promoting transparency, realigning safer care incentives, and informing patients and families about patient safety.

Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic.

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Washington, DC: United States Government Accountability Office; May 20, 2020. Publication GAO-20-576R.

This US Government Accountability Office (GAO) report highlights the chronic shortfalls in nursing home infection control programs. The GAO analyzed survey data from the Centers for Medicare & Medicaid Services (CMS) and found 82% (13,299) of nursing homes surveyed were cited in one or more years between 2013-2017 and in each individual year, 40% of nursing homes had infection control and prevention deficiencies that continued through 2018 and 2019. While the majority of the citations did not indicate harm to nursing home residents and were rarely associated with enforcement actions, the GAO intends to examine CMS oversight of infection and control in the near future. In light of the COVID-19 pandemic, these findings are particularly concerning.

Do some surgical implants do more harm than good?

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Groopman J. New Yorker Online. April 13, 2020.

Medical devices support quality of life but must be designed appropriately and managed carefully to ensure safety over time. This feature discusses industry processes that reduce the reliability of surgical implants, including gaps and weaknesses in regulatory oversight.

Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust.

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NHS Improvement. Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust. NHS England. March 2020.

In-depth incident investigations provide details of care process examinations to motivate learning and improvement. This report examines cardiac surgery patient mortality at a National Health Service Trust over a 5-year period. It highlights weakness in professionalism at the individual and organization level as a contributor to the preventable patient deaths catalogued over that time.

Shifting the Mindset: A Closer Look at Hospital Complaints.

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Newcastle upon Tyne, UK: Healthwatch; January 2020.

Organizations need to do more than report and collect complaint data to realize improvements based on what is compiled. This report highlights weaknesses in the UK National Health Service (NHS) incident reporting program. It argues that an approach involving improved public and organizational access to complaint information will optimize learning.

Preeminent hospitals penalized over rates of patients’ injuries.

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Rau J. Kaiser Health News. January 30, 2020.

Medicare reimbursement restrictions are a controversial stimulus to motivate hospital acquired condition reduction efforts. This news article examines the legacy of the penalties, the data's ability to be effectively applied across various types of institutions, and the lack of direct connection to improvements.

An Organisation Losing its Memory? Patient Safety Alerts: Implementation, Monitoring and Regulation in England

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Cousins D, Accidents A against M.; 2020.

Health care organizations can learn from internal and external incidents to identify potential patient safety risks and incorporate care process improvements. This report suggests that England’s National Health Service has yet to build accountability and reliability into its response to practice alerts. The authors share 4 primary concerns and recommendations to address the alert compliance gaps that focus on clarity on action expected, transparency, communication and monitoring.

The role of racism as a core patient safety issue.

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Feeley D, Torres T. Healthcare Executive. 2020;35:58-61.

A variety of biases can reduce the effectiveness and safety of care. This commentary focuses on racial bias and highlights its deleterious impact on maternity care and maternal safety. The authors suggest tactics to improve listening, implicit bias acknowledgement and data standardization as strategies to counteract the trend.

Mid Staffs scandal: 10 years on, inquiry chair worries NHS staff too scared to speak up.

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Lintern S. The Independent. January 15, 2020.

The Francis report is a primary example of a large-scale examinations of health care system failure. This story highlights that transparency, duty of candor and whistleblowing protections have improved since the report’s release a decade ago but that more work needs to be done to fully embed a culture of safety throughout the United Kingdom National Health Service.

Prescription drug overload: critics fighting to curb an epidemic of medication side effects.

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Weisman R. Boston Globe. January 13, 2020.

Polypharmacy is a known contributor to adverse drug events in older adults. This story discusses strategies such as brown bag reviews and deprescribing to minimize overprescribing that could contribute to harm.

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