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Shea T, De Cieri H, Vu T, et al. Safety Sci. 2021;143:105413.
Assessing safety climate is critical to understanding how organizational efforts can improve safety. This review identified deficiencies and inconsistencies in the way that safety climate has been conceptualized and measured. The authors underscore the importance of a consistent approach to measuring safety climate in order to evaluate its impact on patient safety outcomes.
Pinnock R, Ritchie D, Gallagher S, et al. Adv Health Sci Educ Theory Pract. 2021;26(3):785-809.
Cognition is a recognized human factor that can contribute to medical error. This systematic review explored whether mindful practice can improve diagnosis in healthcare. Of the 33 included studies, the majority were non-empirical; however, the authors tentatively conclude that mindful practice may be a promising method to improve diagnostic accuracy and reduce error.

Graber ML, Schrandt S. Evanston, IL:  Society to Improve Diagnosis in Medicine;  September 8, 2021. 

This report summarizes the results of a project that examined how the literature and various stakeholders consider challenges and opportunities for improving diagnosis during telemedicine interactions. Both areas of concern and potential were highlighted to engage researchers, educators, and clinicians in the implementation and use of telediagnosis that is safe and of high-value for patients and families.

Bajaj K, de Roche A, Goffman D. Rockville, MD: Agency for Healthcare Research and Quality; September 2021. AHRQ Publication No. 20(21)-0040-6-EF.

Maternal safety is threatened by systemic biases, care complexities, and diagnostic issues. This issue brief explores the role of diagnostic error in maternal morbidity and mortality, the preventability of common problems such as maternal hemorrhage, and the importance of multidisciplinary efforts to realize improvement. The brief focuses on events occurring during childbirth and up to a week postpartum.
Fernández‐Aguilar C, Martín‐Martín JJ, Minué Lorenzo S, et al. J Eval Clin Pract. 2021;Epub Aug 11.
Heuristics, or the use of mental shortcuts based on experience or trial and error that allow clinicians to quickly assess or diagnose a problem, can sometimes result in misdiagnosis. Three types of heuristics are explored in this study of primary care diagnostic error: representativeness, availability, and overconfidence. While a diagnostic error was identified in nearly 10% of cases, there was no significant correlation between the use of heuristics and diagnostic error.
Waddell AE, Gratzer D. Can J Psychiatry. 2021:070674372110365.
Safety gaps in mental health care offers a limited view if focused primarily on patient suicide. This commentary calls for Canadian psychiatric professionals to examine the safety of their patients from a system perspective to develop a research and practice improvement strategy.

Rockville, MD: Agency for Healthcare Research and Quality; September 9, 2021. PA-21-267. 

This funding opportunity supports large research demonstration and implementation projects applying existing strategies to understand and reduce adverse events in ambulatory and long-term care settings. Projects focused on preventing harm in disadvantaged populations to improve equity are of particular interest. The funding cycle will be active through May 27, 2024.
Burrus S, Hall M, Tooley E, et al. Pediatrics. 2021;148(3):e2020030346.
Based on analysis of four years of data submitted to the Child Health Patient Safety Organization (CHILDPSO), researchers sought to identify types of serious safety events and contributing factors. Three main groups of serious safety events were identified: patient care management, procedural errors, and product or device errors. Contributing factors included lack of situational awareness, process failures, and failure to communicate effectively.
Casey T, Turner N, Hu X, et al. J Safety Res. 2021;78:303-313.
Many factors influence the success of implementation and sustainment of patient safety interventions. Through a review of 38 research articles about safety training, researchers were able to develop a theoretical framework integrating safety training engagement and application of learned skills. They discuss individual, organizational, and contextual factors that influence safety training engagement and application.
Fenton SH, Giannangelo KL, Stanfill MH. J Am Med Inform Assoc. 2021;Epub Sep 3.
The World Health Organization (WHO) released the International Classification of Diseases, 11th Revision (ICD-11) in 2018. In addition to the medical entities such as disease and injury, it contains a second component, the ICD-11 Mortality and Morbidity Statistics (MMS) linearization. The authors evaluated whether the ICD-11 MMS is appropriate for use in patient safety and quality or if a USA-specific clinical modification is necessary. 
Korenstein D, Harris RP, Elshaug AG, et al. J Gen Intern Med. 2021;36(7):2105-2110.
Provider and patient underestimation of harms of tests and treatments may lead to over treatment. This article presents seven domains of harm of tests and treatment which warrant comprehensive research: (1) physical impairment, (2) psychological distress, (3) social disruption, (4) disruption in connection to healthcare, (5) labeling, (6) financial impact, and (7) treatment burden. Research is especially important in vulnerable patient populations.
Newman B, Joseph K, Chauhan A, et al. Health Expect. 2021;Epub Aug 26.
Patients and families are essential partners in identifying and preventing safety events. This systematic review characterizes patient engagement along a continuum of engagement that includes consultation (e.g., patients are invited to provide input about a specific safety issue), involvement (e.g., patients are asked about their preferences/concerns and given the opportunity to engage with practitioners about a specific issue), and partnership/leadership (e.g., patients ‘work’ with practitioners to improve the safety of their care, often using tools designed to empower patients to alert practitioners to concerns).
O’Connor P, Madden C, O’Dowd E, et al. Int J Qual Health Care. 2021;33(3):mzab117.
There are many challenges associated with detecting and measuring patient safety events. This meta-review provides an overview of approaches to measuring and monitoring safety in primary care. The authors suggest that instead of developing new methods for measuring and monitoring safety, researchers should focus on expanding the generalizability and comparability of existing methods, many of which are readily available, quick to administer, do not require external involvement, and are inexpensive.
Dave N, Bui S, Morgan C, et al. BMJ Qual Saf. 2021;Epub Aug 20.
This systematic review provides an update to McDonald et al’s 2013 review of strategies to reduce diagnostic error.  Technique (e.g., changes in equipment) and technology-based (e.g. trigger tools) interventions were the most studied intervention types. Future research on educational and personnel changes would be useful to determine the value of these types of interventions.
Keister LA, Stecher C, Aronson B, et al. BMC Public Health. 2021;21(1):1518.
Constrained diagnostic situations in the emergency department (ED), such as crowding, can impact safe care. Based on multiple years of electronic health record data from one ED at a large U.S. hospital, researchers found that providers were significantly less likely to prescribe opioids during constrained diagnostic situations and less likely to prescribe opioids to high-risk patients or racial/ethnic minorities.

National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2021.

Misdiagnosis of severe cardiovascular events is a primary concern to the diagnostic safety community due to its prevalence and potential for harm. This report summarizes a session discussion on the existing evidence base on improving diagnosis for these conditions and explore opportunities for improvement.
Fernandez Branson C, Williams M, Chan TM, et al. BMJ Qual Saf. 2021;Epub Jul 27.
Receiving feedback from colleagues may improve clinicians’ diagnostic reasoning skills. By building on existing models such as Safer Dx, and collaborating with professionals outside of the healthcare field, researchers developed the Diagnosis Learning Cycle, a model intended to improve diagnosis through peer feedback.
King CR, Abraham J, Fritz BA, et al. PLoS ONE. 2021;16(7):e0254358.
Analysis of canceled medication orders has been used to estimate medication ordering errors. Using the same dataset analyzed in their 2017 study, the authors update the analysis using machine learning to predict medication ordering errors and associated factors. Results indicate machine learning may be useful in understanding risk factors involved with medication ordering errors.
Petrosoniak A, Fan M, Hicks CM, et al. BMJ Qual Saf. 2021;30(9):739-746.
Trauma resuscitation is a complex, specialized process with a high risk for errors. Researchers analyzed videotapes of in situ simulations to evaluate latent safety events occurring during trauma resuscitation. Themes influencing latent safety events related to physical workspace, mental model formation, equipment, unclear accountability, demands exceeding individuals’ capacity, and task-specific issues.
Pinheiro LC, Reshetnyak E, Safford MM, et al. Med Care. 2021;Epub Aug 14.
Prior research has found that racial/ethnic minorities may be at higher risk for adverse patient safety outcomes. This study evaluated racial disparities in self-reported adverse events based on cross-sectional survey data collected as part of a national, prospective cohort evaluating stroke mortality. Findings show that Black participants were significantly more likely to report a preventable adverse event attributable to poor care coordination (e.g., drug-drug interaction, emergency department visitor, or hospitalization) compared to White participants.