The PSNet Collection

Stop using these adult bed rails, warns the Consumer Product Safety Commission.

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Treisman R. National Public Radio. June 6, 2022

Bedrails are used in hospitals and at home to minimize falls despite the potential to contribute to patient harm. This news article summarizes a government recall of ten models of home bed rail devices due to entrapment incidents.

Antifatness in the surgical setting.

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Andreou A. Scientific American. May 26, 2022.

Negative comments and attitudes indicate a lack of professionalism that can affect patient care. This article shares concerns about surgeon biases toward patients who are overweight and calls for clinicians to recognize the problem and address it.

CMS proposal to suppress hospital safety data angers advocates — agency says COVID disruptions, staff shortages hamper ability to fairly score poor performers.

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Clark C. MedPage Today. May 20, 2022.

Public reporting of safety measures is considered a hallmark of health care transparency. This article discusses a proposed change to reporting requirements in the Hospital-Acquired Condition Reduction Program (HACRP). The change would limit the sharing of patient safety indicator data that informs Care Compare and hospital Medicare reimbursements.

Nurse Vaught sentenced for deadly medical error.

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DePeau-Wilson M. MedPage Today. May 13, 2022.

Disciplinary actions against clinicians who err continue despite awareness efforts to inhibit them. This article summarizes reaction to the sentencing of a nurse in a high-profile medication error case. It discusses reverberations throughout healthcare that will affect patient safety efforts.

At US hospitals, a drug mix-up is just a few keystrokes away.

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Kelman B. Kaiser Health News. April 29, 2022.

Technological solutions harbor unique risks that can result in patient harm. This article shares a response to reports of automated dispensing cabinet (ADC) menu selection limitations that contribute to mistakes. The piece suggests the implementation of a 5-letter search requirement prior to removing a medication from an ADC. It provides an update on industry response to this forcing function recommendation.

Woman works to end Black maternal health crisis after daughter dies after giving birth.

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Kindelan K. ABC News. April 14, 2022.

Maternal injury is a persistent challenge in the Black community. This article discusses the case of one mother whose discounted health concerns contributed to diagnostic delay and death. The piece shares social media tools to assist Black mothers in keeping themselves safe during pregnancy and after birth.

Nurses: Guilty verdict for dosing mistake could cost lives.

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Loller T. Associated Press. March 30, 2022.

Reporting medical errors, learning from them, and improving systems is a cornerstone of improving patient safety. A just culture centers on moving from blaming individuals for medical errors towards a systems-based approach to learning what went on, in order to prevent similar errors in the future. The recent conviction of a nurse involved in the death of a patient has raised concerns that clinicians may not disclose medical errors out of fear of criminal prosecution and conviction.

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.

Dying for Care.

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Stein L, Fraser J, Penzenstadler N et al. USA Today. March 10, 2022.

Nursing home residents, staff, and care processes were particularly vulnerable to COVID-19. This collection of resources examines data and documentation involving one nursing home chain to reveal systemic problems that contributed to failure. It shares family stories that illustrate how COVID affected care in long-term care environments.

Bias in mental health diagnosis gets in the way of treatment.

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Garb HN. Psyche. March 22, 2022.

A wide array of biases can affect clinical judgement and contribute to diagnostic error. This article discusses the impact of implicit biases, test inaccuracy, and data weaknesses in diagnosis of mental health conditions in both children and adults. The author provides recommendations for clinicians and researchers to reduce the impact of bias on diagnosis.

A widow’s mission to change NC dental sedation rules.

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Blythe A. NC Health News. March 10, 2022

Patient harm in dentistry is receiving increased attention and scrutiny. This story covers a medication incident and the lack of safety support that contributed to the death of a patient receiving oral surgery. It discusses the response of the patient’s family and their work to change regulations for dental sedation.

She was headed to a locked psych ward. Then an ER doctor made a startling discovery.

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Boodman SG. Washington Post. February 12, 2022.

Misdiagnosis over a long period of time can be acerbated by stigma and cognitive bias. This news story illustrates the problem of omissions due to potential stigma associated with patient mental health issues that contributed to a missed diagnosis. The author discusses how clinician experience led to flagging of a different testing approach to reveal a diagnosis that, once addressed, improved the patient's health.

Nowhere is safe: record number of patients contracted Covid in the hospital in January.

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Levy R, Vestal AJ. Politico. February 19, 2022.

Transmission of COVID-19 in the health care setting continues to be a concern. This article discusses an analysis of US government statistics tracking hospital-acquired COVID-19 infections and reasons that control efforts may be lagging, which include visitor masking choices and health care worker return to work post-COVID-19 behaviors.

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.

COVID Risk In Hospitals.

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Weber L, Jewett C. Kaiser Health News. 2021-2022.

The infectious nature of COVID continues to impact the safety of hospitalized patients. This article series examines factors contributing to hospital-acquired COVID-19 infection that include weaknesses in oversight, patient legal protections, and documentation.

To eliminate bias, some seek out doctors of their own race or ethnicity.

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Glicksman E. Washington Post. December 11, 2021.

A successful patient/physician relationship enables care that is specific for the individual, their unique concerns, and distinct lifestyles. This article discusses patient choice in physicians as a strategy to reduce the impact of implicit ethnic bias, while arguing that fundamental change will occur only by reducing racism through system change.

How nursing homes’ worst offenses are hidden from the public.

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Gebeloff R, Thomas K, Silver-Greenberg J. New York Times. December 9, 2021.

Nursing homes harbor numerous challenges to patient safety and they should be transparently reported and acted upon to ensure improvement. This news investigation discusses a gap in the reporting and inspection of nursing home incidents that undermines the ability of the US nursing home rating system to inform consumer long term care facility choice.

Her husband died by suicide. She sued his pain doctors—a rare challenge over an opioid dose reduction.

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Joseph A. Stat News. November 22, 2021

The opioid epidemic has put regulatory and professional pressures on the tapering of pain medications that have had unintended consequences for patients resulting in harm. This news story discusses how one family used legal means to address systemic gaps and clinical missteps that resulted in patient suicide due to lack of appropriate pain control.

ERs are swamped with seriously ill patients, although many don’t have Covid.

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Wells K. Health Shots. National Public Radio. October 29, 2021.

Emergency department (ED) crowding stemming from treatment delays and deferrals resulting from COVID concerns is an emerging problem. This article discusses how ED crowding affects patients and clinical teams to reduce safety and effectiveness.

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