The PSNet Collection

Training Program for Nurses on Shift Work and Long Work Hours.

NIOSH [2015]. NIOSH training for nurses on shift work and long work hours. By Caruso CC, Geiger-Brown J, Takahashi M, Trinkoff A, Nakata A. Cincinnati, OH: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2015-115 (Revised 10/2021)

Nurse fatigue has been associated with diminished decision-making skills that can contribute to patient harm. This online training program for clinicians and administrators will explore hazards related to nurse fatigue and provide strategies to address behaviors and systems that increase these risks.

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.

Using performance improvement to enhance time-out compliance and prevent wrong-site surgery.

Vance ME, Proctor T, Schmidt KA. AORN J. 2021;113(6):635-642.

The perioperative setting is a high-risk environment. This continuing education model discusses safety threats and evidence-based best practices to deliver nursing care in perioperative settings and promote a culture of safety.

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

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.

Geriatric medication reconciliation in the home setting.

Taylor K. American Nurse J. 2021;16(7):14-17.

Medication reconciliation reduces the potential for problems in complicated medication regimens. This article shares strategies for reconciling medications for older patients in the home to ensure their medication use is safe and appropriate.

An Inadvertent Bolus of Norepinephrine.

May 26, 2021

A 64-year-old woman was admitted to the hospital for aortic valve replacement and aortic aneurysm repair. Following surgery, she became hypotensive and was given intravenous fluid boluses and vasopressor support with norepinephrine. On postoperative day 2, a fluid bolus was ordered; however, the fluid bag was attached to the IV line that had the vasopressor at a Y-site and the bolus was initiated.

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: 9780309685061.

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.

ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings.

Horsham, PA: Institute of Safe Medication Practices; 2021

Long-term care patients often have concurrent conditions that increase their risk of medication error. This fact sheet provides a list of potential high-alert medications prevalent in long-term care settings that should be administered with particular care due to the heightened potential for harm. A past PSNet perspective discussed medication safety in nursing homes.

Nursing and Patient Safety

April 21, 2021

Nurses play a critical role in patient safety through their constant presence at the patient's bedside. However, staffing issues and suboptimal working conditions can impede a nurse’s ability to detect and prevent adverse events.

Taking action to close the loop on diagnostic error: a Constellation and SIDM Collaborative.

Constellation, Society to Improve Diagnosis in Medicine.

The processes supporting safe and accurate diagnosis involve many steps that are prone to human error. This collaborative will engage teams to explore test result management and follow-up coordination to improve timeliness, collaboration, and communication to support safe care. The launch of the collaborative has been delayed due to COVID-19.

The Impact of Communication on Medication Errors

March 15, 2021

A 93-year-old man on warfarin with chronic heart failure, atrial fibrillation, and a ventricular assist device (VAD) was admitted to the hospital upon referral from the VAD team due to an elevated internal normalized ratio (INR) of 13.4. During medication review, the hospital team found that his prescribed warfarin dose was 4 mg daily on Mondays and Fridays and 3 mg daily on all other days of the week; this prescription was filled with 1 mg tablets. However, his medication list also included an old prescription for 5 mg tablets.

Medication Administration Errors

March 12, 2021

Medication administration errors are a persistent patient safety problem. Increasing the safety of medication administration requires a multifaceted, system-level approach that spans all areas of health care delivery, such as primary, specialty, inpatient, and community-based care.

ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations.

Horsham, PA; Institute for Safe Medication Practices; February 12, 2021.

A handy list for medical personnel to ensure and implement safe prescribing practices by avoiding use of these dangerous shortcuts.

The impact of critical incidents on nurses and midwives: a systematic review.

Buhlmann M, Ewens B, Rashidi A. J Clin Nurs. 2020;Epub Dec 23.

Adverse events can have significant impacts on the providers involved. This systematic review explored the experiences of critical incidents on nurses and midwives and their perceived support from the healthcare system. The article discusses the emotional, physical, and professional impacts; perceptions of personal, peer and workplace support; and how nurses and midwives move forward and cope with the impact of critical incidents.

Understanding the peer, manager, and system influence on patient safety.

Forbes TH, Wynn J, Anderson T, et al. Nurs Manage. 2020;51(12):36-42.

A positive safety culture can improve nursing-sensitive patient safety outcomes. This secondary analysis of Hospital Survey on Patient Safety scores indicate that manager- and peer-level factors greatly influence clinical nurses’ perceptions of patient safety and nonpunitive responses to error. The authors discuss the importance of the role of organizational leaders, managers and staff in creating a safe patient care environment

Risk of misdiagnosis and delayed diagnosis with COVID-19: a syndemic approach.

Muhrer JC. Nurs Pract. 2021;46(2):44-49.

The COVID-19 pandemic has led to wide-ranging changes to health care delivery, some of which may negatively impact patient outcomes.The authors use a syndemic perspective to discuss existing challenges interfering with diagnosis (structural, socioeconomic, patient-related, and provider-related), how the COVID-19 pandemic has exacerbated those challenges, and strategies related to nurse practitioners and community health workers to improve diagnosis.

Meitheal Pharmaceuticals, Inc. issues voluntary nationwide recall of Cisatracurium Besylate Injection, USP 10mg per 5mL due to mislabeling.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 27, 2021.

Labeling mistakes in the pharmaceutical production cycle can remain undetected until the affected medication reaches a patient. This alert reports a recall of a neuromuscular blocker for use in surgery due to it being mislabeled as a medication to increase blood pressure.

Impact of alarm fatigue on the work of nurses in an intensive care environment--a systematic review.

Lewandowska K, Weisbrot M, Cieloszyk A, et al. Int J Environ Res Public Health. 2020;17(22):8409.

Alarm fatigue, which can lead to desensitization and threaten patient safety, is particularly concerning in intensive care settings. This systematic review concluded that alarm fatigue may have serious consequences for both patients and nursing staff. Included studies reported that nurses considered alarms to be burdensome, too frequent, interfering with patient care, and resulted in distrust in the alarm system. These findings point to the need for a strategy for alarm management and measuring alarm fatigue.

Implementation of a parent-centered approach to the preinduction checklist in pediatric surgery.

Arshad SA, Ferguson DM, Garcia EI, et al. J Surg Res. 2021;257:455-461.

Engaging patients and families is an important strategy in ensuring safe health care delivery. In this prospective, observational study, use of a parent-centered script did not improve parent engagement during the preinduction checklist and resulted in an expected decline in checklist adherence.

Exploring the association between organizational safety climate, failure to rescue, and mortality in inpatient surgical units.

Bacon CT, McCoy TP, Henshaw DS. J Nurs Adm. 2021;51(1) :12-18.

Lack of communication and interpersonal dynamics can contribute to failure to rescue. This study surveyed 262 surgical staff about perceived safety climate, but the authors did not find an association between organizational safety culture and failure to rescue or inpatient mortality.

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