The PSNet Collection

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.

Maternal Safety

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Opioid prescribing to US children and young adults in 2019.

Chua K-P, Brummett CM, Conti RM, et al. Pediatrics. 2021;Epub Aug 16.

Despite public policies and guidelines to reduce opioid prescribing, providers continue to overprescribe these medications to children, adolescents, and young adults. In this analysis of US retail pharmacy data, 3.5% of US children and young adults were dispensed at least one opioid prescription; nearly half of those included at least one factor indicating they were high risk. Consistent with prior research, dentists and surgeons were the most frequent prescribers, writing 61% of all opiate prescriptions.

The Safety of Maternity Services in England.

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.

Long-term care nurses' experiences with patient safety incident management: a qualitative study.

Serre N, Espin S, Indar A, et al. J Nurs Care Qual. 2021;Epub Jul 15.

Safety concerns are common in long-term care (LTC) facilities. This qualitative study of LTC nurses explored nurses’ experiences managing patient safety incidents (PSI). Three categories were identified: commitment to resident safety, workplace culture, and emotional reaction. Barriers and facilitators were also discussed.

Federal speech rulings may embolden health care workers to call out safety issues.

Meyer H. Kaiser Health News. July 9, 2021.

Whistleblower protections are a key component to raising awareness of safety issues in work environments. This news story examines how US federal law has opened the door for the media as a platform for employees to highlight conditions that reduce staff and patient safety in health care environments.

Structural racism and the COVID-19 experience in the United States.

Dickinson KL, Roberts JD, Banacos N, et al. Health Secur. 2021;19(S1):S14-S26.

The COVID-19 pandemic highlighted the continued existence of structural racism and its disproportionate impact on the health of communities of color. This study examines the experiences of non-White and White communities and the negative impact of structural racism on the non-White communities. The authors call for bold action emphasizing the need for structural changes.

Opioids in the United Kingdom: safety and surveillance during COVID-19.

Osborne V. Curr Opin Psychiatry. 2021;34(4):357-362.

The opioid epidemic is an ongoing patient safety issue. This literature review examined the impact of the COVID-19 pandemic on opioid surveillance research in the United Kingdom. Of studies conducted during the pandemic, most explored the impact of the pandemic on access to opioids or opioid substitution therapy.

Closing Death’s Door: Legal Innovations to End the Epidemic of Healthcare Harm.

Saks M, Landsman S. New York, NY: Oxford University Press; 2021. ISBN: 9780190667986.

A weave of systemic factors contributes to the persistent presence of error in medicine. This publication summarizes the development of the patient safety movement and discusses legal and policy approaches as promising avenues for generating the changes needed to reduce iatrogenic harm and sustain improvement.

Medical malpractice claims by members of the uniformed services.

Department of Defense Office of General Counsel. 32 CFR Part 45. Fed Register. 86(115); June 17, 2021:32194-32215.

Organizations with safety cultures facilitate the ability for an injured patient to seek an effective response to untoward incidents. This United States rule outlines the standards that enable members of the armed forces to file claims should they be harmed while in the military health care system.

Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices.

Cheraghi-Sohi S, Holland F, Singh H, et al. BMJ Qual Saf. 2021;Epub Jun 14.

Diagnostic error continues to be a source of preventable patient harm. The authors undertook a retrospective review of primary care consultations to identify incidence, origin and avoidable harm of missed diagnostic opportunities (MDO). Nearly three-quarters of MDO involved multiple process breakdowns (e.g., history taking, misinterpretation of diagnostic tests, or lack of follow up). Just over one third resulted in moderate to severe avoidable patient harm. Because the majority of MDO involve several contributing factors, interventions, including policy changes, should be multipronged.

Moving beyond the weekend effect: how can we best target interventions to improve patient care?

Marang-van de Mheen PJ, Vincent CA. BMJ Qual Saf. 2021;30(7):525-528.

Research has shown that patients admitted to the hospital on the weekend may experience worse outcomes compared to those admitted on weekdays (the ‘weekend effect’). This editorial highlights the challenges to empirically evaluate the underlying mechanisms contributing to the weekend effect. The authors propose viewing the weekend effect as a proxy for staffing levels and the influence of other factors influencing outcomes for patients admitted on weekends, such as patient acuity, clinician skill-mix and access to diagnostic tests or other ancillary services.

Missing diagnoses during the COVID-19 pandemic: a year in review.

Pifarré i Arolas H, Vidal-Alaball J, Gil J, et al. Int J Environ Res Public Health. 2021;18(10):5335.

The beginning of the COVID-19 pandemic immediately changed how patients sought healthcare. This study analyzed the change frequency of diagnoses made in 2019 compared to 2020 in one region of Spain. On average, the number of diagnoses declined 31% from 2019 to 2020, with cancer diagnoses declining by nearly 50%. As COVID-19 cases continue to decrease in many areas in 2021, the authors recommend local, regional, and national public health leaders prioritize plans to target under-diagnosed conditions.

Ethical challenges in child abuse: what is the harm of a misdiagnosis?

Brown SD. Pediatr Radiol. 2021;51(6):1070-1075.

Misdiagnosis of child abuse has far-reaching implications. This commentary discusses the ethical tensions faced by pediatric radiologists of both over- and under-diagnosing child abuse. The author suggests ways that physicians and professional societies can partner with legal advocates to create a more balanced pool of experts to alleviate perceptions of bias and acknowledge harms of misdiagnosed child abuse.

Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals.

McHugh MD, Aiken LH, Sloane DM, et al. The Lancet. 2021;397(10288):1905-1913.

While research shows that better nurse staffing ratios are associated with improved patient outcomes, policies setting minimum nurse-to-patient ratios in hospitals are rarely implemented. In 2016, select Queensland (Australia) hospitals implemented minimum nurse staffing ratios. Compared to hospitals that did not implement minimum nurse staffing ratios, length of stay, mortality, and readmission rates were significantly lower in intervention hospitals, providing evidence, once again, that minimum staffing ratios can improve patient outcomes.

Association of opioid consumption profiles after hospitalization with risk of adverse health care events.

Kurteva S, Abrahamowicz M, Gomes T, et al. JAMA Netw Open. 2021;4(5):e218782.

Using administrative data and patient interviews, this study sought to estimate opioid-related adverse events in adults discharged from one Canadian hospital. Among patients who filled at least one opioid prescription in the 90 days following hospital discharge, approximately 16% experienced an opioid-related emergency department visit, hospital readmission, or death. Longer duration of use and higher daily dose were associated with increased risk of adverse events. Results from this study can inform policies and strategies to limit opioid prescription dose and duration.

Influence of opioid prescription policy on overdoses and related adverse effects in a primary care population.

Harder VS, Plante TB, Koh I, et al. J Gen Intern Med. 2021;Epub May 6.

In an effort to reduce opioid overdose and adverse events, many states enacted policies limiting dose and duration of opioid prescriptions. This study analyzed the rates of opioid overdose and adverse effects in primary care patients before and after the implementation of prescribing policies in Vermont. While there was no change in opioid overdose rates following implementation, there was a 78% decrease in adverse effects rates, particularly among patients with chronic opioid prescriptions and opioid-naïve patients. Statewide policies limiting dose and duration of opioid prescriptions may have positive results among primary care patients.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.

National Academies of Sciences, Engineering, and Medicine. Washington DC: National Academies Press; 2021. ISBN (Pre-publication): 9780309491518.

Health care system safety and effectiveness requires an engaged and empowered nursing workforce. This report builds on the foundation of nursing as a core care contributor. It shares a framework positioning nurses to improve equity, reduce disparities and support family-centered care in the future through education, healthy work environments and enhanced professional autonomy.

Peer Review of a Report on Strategies to Improve Patient Safety.

Washington DC: National Academies of Sciences, Engineering, and Medicine; 2021. ISBN: 9780309462808.

The Patient Safety and Quality Improvement Act of 2005 requires the Secretary of the U.S. Department of Health and Human Services (HHS), in consultation with the Director of the Agency for Healthcare Research and Quality, to prepare a report for Congress on effective strategies for reducing medical errors and increasing patient safety and on measures to encourage the appropriate use of such strategies. The Act also requires that a draft of the report be made available for public comment and review by the Institute of Medicine (now the National Academy of Medicine (NAM)). This publication reflects NAM’s review of the draft report. HHS is in the process of preparing a final report due to Congress in December 2021.

Compelled disclosure of confidential information in patient safety research.

Du L, Murdoch B, Chiu C, et al. J Patient Saf. 2021;17(3):200-206.

Ensuring research participants’ confidentiality is of paramount importance to conducting patient safety research. This article explores how confidentiality is presented in informed consent templates, as compared to current case law in Canada and the United States. Researchers should continue to reassure participants that attempts to force disclosure of confidential research information are rarely successful, and describe the steps taken to protect their confidentiality.

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Provide Feedback Anonymously

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users