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.

HEAR Her Concerns.

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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.

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.

Preventing home medication administration errors.

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Yin HS, Neuspiel DR, Paul IM, et al. Pediatrics. 2021;148:e2021054666.

Children with complex home care needs are vulnerable to medication errors. This guideline suggests strategies to enhance medication safety at home that include focusing on health literacy, prescriber actions, dosing tool appropriateness, communication, and training of caregivers. A March 18, 2022 webinar will highlight factors contributing to medication errors in the home and outline strategies to reduce their impact.

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.

Lessons Learned? Building a Culture of Patient Safety Within the Veterans Health Administration.

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US House of Representatives Committee on Veterans' Affairs Subcommittee on Health. 117th Cong. 1^st 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.

A crisis within a crisis.

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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.

The pain was unbearable. So why did doctors turn her away?

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Szalavitz M. Wired Magazine. August 11, 2021.

The opioid epidemic has contributed to uncertainties for pain management patients that result in harm. This article discusses how an endometriosis patient was unable to get prescriptions to manage her pain due to misinformation generated through screening tools designed to identify opioid misuse and inform prescribing decisions.

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.

Unite for Safe Care.

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Patient Safety Movement. September 17, 2021.

Patient safety is a global challenge for the health care community. This webinar coincided with World Patient Safety Day and presented two tracks for both the profession and the public that highlighted issues impacting maternal care safety and high reliability. Those who have lost their lives to medical error were also honored during the event. The session speakers included Tedros Adhanom Ghebreyesus, PhD, MSc, Jeff Brady, MD, and Albert Wu, MD.

Unwell Women: Misdiagnosis and Myth in a Man-Made World.

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Cleghorn E. New York, NY: Dutton; 2021. ISBN: 9780593182956.

Women have been affected by implicit bias that undermines the safety of their care and trust in the medical system. This book shares the history anchoring the mindsets driving ineffective care for women and a discussion of the author’s long-term lupus misdiagnosis.

How medical jargon can make COVID health disparities even worse.

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Kritz F. Shots. National Public Radio; May 24, 2021.

Health literacy efforts address challenges related to both language and effective communication tactics. This story discussed how lack of language and information clarity reduced patient education effectiveness during the pandemic and highlights several efforts to address them including information product translation services.

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.

Bearing the Burden: Black Mothers in America.

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Weiser S. The New Yorker and Retro Report; 2021.

Disparities in maternal care have become apparent as a public health concern during the COVID-19 pandemic. This short film spotlights inequities and biases that Black mothers face, that reduce the safety of their care. Midwives are offered as a strategy for improving the safety of maternal care in this patient population.

Cancer diagnoses delayed among prisoners in Washington state.

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Medscape Medical News. May 12, 2021.

Delays and mistakes in health care for distinct patient populations hold improvement lessons for the broader system. This news story highlights problems in correctional system cancer diagnoses and treatment that may indicate other types of prison care delivery problems.

Survey by Ohio regulator shows stress, fatigue among pharmacists at chain stores.

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Kaplan A. NBC News. April 21, 2021.

Pharmacies are high-pressure environments generating conditions that undermine safety. This story highlights working conditions in chain pharmacies that cause concerns for pharmacists in their ability to prepare and dispense medications safely due to lack of appropriate staffing and time to do their jobs.

Black or 'other'? Doctors may be relying on race to make decisions about your health.

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Smith J, Spodak C. CNN. April 25, 2021.

Race-adjusted decision making tools perpetuate the potential for diagnostic error and care delay. This article examines race correction as a form of bias in health care and discusses efforts to reduce the use of race-adjusted algorithms.

Endometriosis affects 1 out of 10 women like me. Yet it often takes a decade to get diagnosed.

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Peikoff L. NBC News. March 31, 2021.

Patients with endometriosis often experience care delays and misdiagnoses that contribute to harm. This news story discusses a patient’s experience with common contributors to delay that include Insufficient clinical knowledge of the disease and a lack of uniform treatment guidance.

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.

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