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Infect Control Hosp Epidemiol. 2022.

 

Health care–associated infections (HAIs) affect patients both during and after hospitalization. The use of patient safety methods as well as traditional infection control practices has resulted in significant successes in curbing HAIs such as central-line bloodstream infections. This set of practice guidelines will be developed and disseminated over the course of 2022 to summarize preemptive actions and implementation strategies for prevention of HAIs.

Sentinel Event Alert. Nov 10 2021;(64):1-7.

Health care disparities are emerging as a core patient safety issue. This alert introduces strategies to align organizational and patient safety strategic goals, such as collection and analysis of community-level performance data, adoption of diversity and inclusion as a precursor to improvement, and development of business cases to support inequity reduction initiatives.

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.
Sentinel Event Alert. 2018;59:1-9 (revised June 18, 2021).
The Joint Commission issues sentinel event alerts to raise awareness regarding risks in the health care setting. This alert highlights physical and verbal violence as a major problem in the workplace, particularly in areas such as the emergency department and inpatient psychiatric units. Other factors associated with violence in health care settings include stressful conditions, understaffing, and lack of organizational policies for recognizing and deescalating hostile behaviors. The alert suggests numerous strategies health care organizations can take to mitigate workplace violence, such as establishing systems across the organization that enable reporting of workplace violence and developing quality improvement initiatives to reduce such incidents. A past PSNet perspective explored how a team at Beth Israel Deaconess Medical Center developed a process to improve workplace safety.
SB 1307, 117th Congress: 2021.
Reporting clinicians who exhibit practice behaviors that are detrimental to safety is challenged by system and cultural norms. This legislation aims to strengthen the US Veterans Health System process for identifying problematic clinicians by underscoring the importance of reporting to a national system that tracks these instances.

La Regina M, Tanzini M, Venneri F, et al for the Italian Network for Health Safety. Dublin, Ireland: International Society for Quality in Health Care; 2021.

The COVID-19 pandemic is a rapidly evolving situation that requires a system orientation to diagnosis, management and post-acute care to keep clinicians, patients, families and communities safe. This set of recommendations is anchored on a human factors approach to provide overarching direction to design systems and approaches to respond to the virus. The recommendations focus on team communication and organizational culture; the diagnostic process; patient and family engagement to reduce spread; hospital, pediatric, and maternity processes and treatments; triage decision ethics; discharge communications; home isolation; psychological safety of staff and patients, and; outcome measures. An appendix covers drug interactions and adverse effects for medications used to treat this patient population. The freely-available full text document will be updated appropriately as Italy continues to respond, learn and amend its approach during the outbreak.
Am Geriatr Soc. 2020;68:908-911.
This policy brief presents the American Geriatric Society’s recommendations for caring for patients with COVID-19 in nursing homes and long-term care facilities. Recommendations focus on the production and distribution of personal protective equipment (PPE), patient transfer between hospitals and nursing homes, public health planning, workforce issues, and payment and tax relief for nursing homes. The brief reflects federal guidance as of April 4, 2020.

American College of Radiology. March 11, 2020.

As COVID-19 spreads globally, there is growing interest in methods for rapid diagnosis and the risk of diagnostic error. Delayed diagnosis of COVID-19 may lead to worse patient outcomes and increased exposure of healthy individuals to the novel coronavirus. Two early studies suggested that chest CT may have a sensitivity as high as 97%. However, higher quality studies have shown that the sensitivity of chest CT is only 67-93% among patients with viral pneumonia and imaging features must be interpreted with caution when the prevalence of SARS-CoV-2 infection is low. Based on the risks of misdiagnosis and viral transmission, the American College of Radiology recommends that CT should not be used to screen for or as a first-line test to diagnose COVID-19. CT should be reserved for hospitalized, symptomatic patients with specific clinical indications.  

Sentinel Event Alert. July 30, 2019;(61):1-5.

Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral anticoagulants (DOACs) require less monitoring than warfarin, they are still associated with an increased risk of patient harm if not prescribed and administered correctly. The Joint Commission has issued a new sentinel event alert to raise awareness of the risks related to DOACs, and in particular, the challenges associated with stopping bleeding in patients on these medications. The alert suggests that health care organizations develop patient education materials, policies, and evidence-based guidelines to ensure that DOACs and reversal agents are used appropriately. A past WebM&M commentary discussed common errors related to the use of DOACs.
Munoz-Price S, Bowdle A, Johnston L, et al. Infect Control Hosp Epidemiol. 2018:1-17.
This expert guidance provides recommendations to help health care facilities develop policies for preventing health care–associated infections in the operating room. The authors build on existing anesthesia safety practices to outline specific actions for infection prevention and control.
Academy of Medical Royal Colleges; AMRC.
Miscommunication due to clinician use of medical jargon and limited patient health literacy is a persistent problem. This guidance suggests that physicians in the United Kingdom adopt a more direct approach to communication with their patients, such as encouraging physicians to write care letters and visit summaries directed to their patients.
AORN J. 2018;107:489-494.
Perioperative medication errors can result in patient harm as well as emotional distress among clinical team members. This guideline summary outlines best practices to ensure surgical teams employ methods to design, implement, and assess medication safety processes and improvements. A related commentary discusses how to integrate the guidelines into frontline care activities.
Benjamin L, Frush K, Shaw K, et al. Ann Emerg Med. 2018;71:e17-e24.
Emergency departments harbor conditions that can hinder safe medication administration for pediatric patients. This policy statement identifies and prioritizes improvements such as implementing kilogram-only weight-based dosing, involving pharmacists in frontline emergency care, and utilizing computerized provider order entry and clinical decision support systems.