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1 - 20 of 95

Andreou A. Scientific AmericanMay 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.

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.

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.

London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294.

Maternal and baby harm in healthcare is a sentinel event manifested by systemic failure. This report serves as the final conclusions of an investigation into 250 cases at a National Health System (NHS) trust. The authors share overarching system improvement suggestions and high-priority recommendations to initiate NHS maternity care improvement.

National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health; Centers for Disease Control and Prevention. 

Maternal harm during and after pregnancy is a sentinel event. This campaign encourages women, families, and health providers to identify and speak up with concerns about maternal care and act on them. The program seeks to inform the design of support systems and tool development that enhance maternal safety.

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.

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.

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.

US House of Representatives Committee on Veterans' Affairs Subcommittee on Health.  117th Cong. 1st Sess (2021).

The Veterans Health Administration is a large complex system that faces various challenges to safe care provision. At this hearing, government administrators testified on current gaps that detract from safe care in the Veteran’s health system. The experts discussed several high-profile misconduct and systemic failure incidents, suggested that the culture and leadership within the system overall enables latency of issues, and outlined actions being taken to address weaknesses.

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.

Ellis NT, Broaddus A. CNN. August 25, 2021. 

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.

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.

Kast S, Gerr M, Black D, et al. “On the Record.” WYPR. August 3, 2021

Misdiagnosis is a persistent challenge for patients and families to navigate. This audio news segment highlights one family's experience with poor care stemming from disrespect and premature closure that resulted in missed diagnosis, unnecessary care, and patient death. The story is coupled with a broader discussion on the extent of diagnostic errors and reasons they occur.

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.

Renault M. Stat. July 28, 2021.

Care and safety concerns for patients, families, and clinicians continue to be challenged by COVID-19. This article discusses the unintended consequences of isolation practices during the pandemic as a contributor to patient harm due to resultant family support barriers and loneliness they caused.