The PSNet Collection

Patient Safety Authority Annual Reports.

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Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.

This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.

Impact of full personal protective equipment on alertness of healthcare workers: a prospective study.

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Wells HJ, Raithatha M, Elhag S, et al. BMJ Open Qual. 2022;11:e001551.

Use of personal protective equipment is necessary to reduce the spread of infectious diseases, such as COVID-19, in healthcare settings. The alertness levels of ICU staff who regularly wore full personal protective equipment (FPPE), i.e., respirator mask, body covering suit, visor, gloves, and hat, were tested when not wearing FPPE and after two hours wearing FPPE. Results show health care worker alertness can be negatively impacted by wearing FPPE for as little as two hours.

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.

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Maternal Safety

The problem with 'My Five Moments for Hand Hygiene'.

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Gould D, Purssell E, Jeanes A, et al. BMJ Qual Saf. 2022;31:322-326.

The “My Five Moments for Hand Hygiene” framework is promoted by the World Health Organization to decrease healthcare-associated infections (HAIs). This article identifies five limitations of the Five Moments and proposes solutions to improve hand hygiene, including capitalizing on infection control measures brought about by the COVID-19 pandemic.

Local Anesthesia-Induced Coma During Total Knee Arthroplasty.

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July 28, 2021

A 61-year-old male was admitted for a right total knee replacement under regional anesthesia. The surgeon – unaware that the anesthesiologist had already performed a right femoral nerve block with 20 ml (100mg) of 0.5% racemic bupivacaine for postoperative analgesia – also infiltrated the arthroplasty wound with 200 mg of ropivacaine. The patient was sedated with an infusion of propofol throughout the procedure.

Healthcare personnel's working conditions in relation to risk behaviours for organism transmission: a mixed-methods study.

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Arvidsson L, Lindberg M, Skytt B, et al. J Clin Nurs. Epub 2021 Jul 6.

Healthcare associated infections (HAI) affect thousands of hospitalized patients each year. This study evaluated working conditions that impact risk behaviors, such as missed hand hygiene, that may contribute to HAI. Main findings indicate that interruptions and working with colleagues were associated with increased risk behaviors.

FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing.

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Silver Springs, MD: US Food and Drug Administration: June 25, 2021.

Incomplete reprocessing of reusable flexible endoscopes can result in nosocomial infection. This announcement highlights recent guidance to improve the safe reuse of bronchoscopes with a focus on scope design, sterile processing, and infection control program management.

Crisis checklists in emergency medicine: another step forward for cognitive aids.

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Chen Y-YK, Arriaga AF. BMJ Qual Saf. 2021;30:689-693.

Checklists and other cognitive aids are used in a variety of clinical settings to improve patient safety. Building on an example from emergency medicine, the authors highlight the importance of implementation science methods to ensure the most effective use of these cognitive aids.

Changes in error patterns in unanticipated trauma deaths during 20 years: in pursuit of zero preventable deaths.

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LaGrone LN, McIntyre LK, Riggle A, et al. J Trauma Acute Care Surg. 2020;89:1046-1053.

The authors examined contributors to error-associated deaths occurring between 1996-2004 and 2005-2014 and identified a shift from deaths occurring during the early phase of care (e.g., failed resuscitation and hemorrhage) to deaths occurring during the recovery phase (e.g., respiratory failure from aspiration). These findings demonstrate that successful implementation of system improvements can resolve process of care issues, but that ongoing evaluation is critical for continuous process improvement.

Racial/ethnic inequities in pregnancy-related morbidity and mortality.

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Minehart RD, Bryant AS, Jackson J, et al. Obstet Gynecol Clin North Am. 2021;48:31-51.

Improving maternal safety and reducing disparities in maternal morbidity and mortality are national priorities. This article discusses inequities in maternal health outcomes and provision of care, factors involved in the relationship between race and health (e.g., racism, social status, health behaviors), and efforts at the national-, state-, and hospital-level to improve obstetric care and outcomes for Black mothers.

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.

Health care workers in the midst of crisis.

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Sentinel Event Alert. Feb 2, 2021;(62):1-7.

Safe patient care is reliant on a healthy healthcare workforce. This alert emphasizes organizational conditions and supporting the wellbeing of clinicians under the stress of providing care during the COVID-19 pandemic.

TeamSTEPPS for the COVID-19 Crisis.

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AHA Team Training.

The COVID-19 crisis requires cooperation and coordination of organizations and providers to address the persistent challenges presented by the pandemic. This on-demand video collection reinforces core TeamSTEPPS; methods that enhance clinician teamwork and communication skills to manage care safety during times of crisis.

An intervention to increase situational awareness and the Culture of Mutual Care (Foco) and its effects during COVID-19 pandemic: a randomized controlled trial and qualitative analysis.

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Kozasa EH, Lacerda SS, Polissici MA, et al. Front Psych. 2020;11:570786.

Situational awareness during critical incidents is a key component of teamwork. This study found that a mutual care training can increase situational awareness for healthcare workers and consequently improve mental health and well-being before and during the COVID-19 pandemic.

The hard talk: dealing with the disruptive physician.

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Rossano JW, Berger S, Penny DJ. Prog Pediatr Cardiol. 2020;59:101315.

Disruptive behavior is a recognized threat to patient safety. This article reviews the scope of the problem, factors leading to disruptive physicians, consequences of disruptive behavior, and strategies for managing disruptive physicians.

When the Lytes Go Out: A Case of Inpatient Cardiac Arrest

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September 30, 2020

A 44-year old man with hypertension and diabetes was admitted with an open wound on the ball of his right foot that could be probed to the bone and evidence of diabetic ketoacidosis. Over the course of the hospitalization, he had ongoing hypokalemia, low magnesium levels, an electrocardiogram showing a prolonged QT interval, ultimately leading to cardiac arrest due to torsades de pointes (an unusual form of ventricular tachycardia that can be fatal if left untreated). The commentary discusses the use of protocol-based management of chronic medical conditions, the inclusion of interprofessio

Without an 'ounce of empathy': their stories show the dangers of being Black and pregnant.

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Ramaswamy SV. Rockland/Westchester Journal News. September 9, 2020.

Implicit and explicit biases affect many facets of the health care delivery system. This story shares African-American patient experiences with bias that reduced the safety of maternity care.

Applying thematic synthesis to interpretation and commentary in epidemiological studies: identifying what contributes to successful interventions to promote hand hygiene in patient care.

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Drey N, Gould D, Purssell E, et al. BMJ Qual Saf. 2020;29:756-763.

This thematic analysis explored variations in the impact of hand hygiene interventions to prevent healthcare-associated infections. The analysis identified several directions for future research, including exploring ways to avoid the Hawthorne effect, embed the interventions into wider patient safety initiatives, and develop systematic approaches to implementation.

Association between surgeon technical skills and patient outcomes.

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Stulberg JJ, Huang R, Kreutzer L, et al. JAMA Surg. 2022;157:219-220.

This study examined variation in operative technical skills among patients undergoing colorectal and non-colorectal procedures and the association with patient outcomes. Higher technical skills were significantly associated with lower rates of complications, unplanned reoperations, and death or serious morbidity. The findings suggest that this skill variation accounts for more than 25% of the variation in patient outcomes.

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