The PSNet Collection

Patient, Medical, and Legal Perspectives of Unsafe Care.

Patient Safety Foundation. October 29, 2021. 10:30--11:30 AM (eastern).

Effective response to medical harm involves a variety of perspectives that are aligned in purpose. This webinar will discuss how different stakeholders might view approaches to medical error management. It will describe how strategies have changed from paternalistic to inclusive processes that consider the impact of mistakes on patients and families and the role of communication is key to achieving fair and honest resolution to adverse incidents.

Association of simulation training with rates of medical malpractice claims among obstetrician-gynecologists.

Schaffer AC, Babayan A, Einbinder JS, et al. Obstet Gynecol. 2021;138(2):246-252.

Adverse events in obstetrics threaten the safety of both maternal and infant patients. This study identified a significant reduction in malpractice claims among obstetrician-gynecologists after participation in simulation training focused on team training and crisis management.

ASHRM 2021 Annual Conference.

American Society for Healthcare Risk Management. October 10-13, 2021 (live); October 25-27, 2021 (virtual).

This virtual session will offer participants a range of educational opportunities that focus on how risk managers can contribute to safe and trusted health care. Sessions will feature topics on support of families after harm and the importance of leadership accountability for highly reliable care.

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.

Communication failures contributing to patient injury in anaesthesia malpractice claims.

Douglas RN, Stephens LS, Posner KL, et al. Br J Anaesth. 2021;127(3):470-478.

Effective communication among providers helps ensure patient safety. Through analysis of perioperative malpractice claims using the Anesthesia Closed Claims Project database, researchers found that communication failures contributed to 43% of total claims, with the majority between the anesthesiologist/anesthesia team and the surgeon/surgery team. Methods to improve perioperative communication are discussed.

Cardinal Health recalls Argyle UVC insertion tray due to missing instructions for use for the Safety Scalpel N11.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.

Delays in treatment due to device misuse or design flaws can result in patient harm. This recall announcement highlights the omission of instructions describing a distinct device feature that, if a surgeon is unaware of it, reduces emergent umbilical vein catheter placement safety. Two deaths have been reported due to problems with the device.

Use systems redesign and the law to prevent medical errors and accidents.

Saks MJ, Landsman S. Stat News. August 4, 2021.

This article introduces the systemic task of medical error reduction and discusses the need for a business case, enterprise-wide accountability and legal process change to drive improvement.

Patient Safety Certificate Program.

American Society for Healthcare Risk Management. Henry B. Gonzalez Convention Center, San Antonio, TX; October 9-10 2021.

This onsite program will cover key patient safety concepts and how to apply them to improve safety. To help prepare attendees for designing and sustaining safety initiatives at their organizations, preconference activities will discuss safety culture, human factors, communication, and leadership development.

2022 IHI Patient Safety Congress

Institute for Healthcare Improvement. Dallas TX. May 16-18, 2022.

This annual conference will host pre-session workshops, panels, and presentations covering a variety of patient safety topics which include the continuum of care, learning systems and leadership.

ISMP Medication Safety Intensive.

Institute for Safe Medication Practices. December 2-3, 2021.

This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.

AMC PSO Resource Center.

Academic Medical Center Patient Safety Organization.

Patient Safety organizations (PSO) are in a unique position to educate their members and the larger community on patient safety challenges. This PSO resource collection includes guidelines, papers and alerts drawn from the experiences the membership group to inform action covering topics such as virtual visits and inter-hospital transfers.

Redesigning Event Review with RCA2

Institute for Healthcare Improvement. September 7 - November 16, 2021.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.

Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries.

Abela G. J Tissue Viability. 2021;30(3):339-345.

Hospital-acquired pressure injuries (HAPI) can lead to increase costs and length of stay. Through root cause analysis, this geriatric rehabilitation hospital identified factors that contributed to the development of HAPI in its facility. Recommendations for improvement targeted both system- and human-level factors.

Burnout and sources of stress among health care risk managers and patient safety personnel during the COVID-19 pandemic: a pilot study.

Card AJ. Disaster Med Public Health Prep. 2021:1-3.

While health professional burnout and stress related to the COVID-19 pandemic have been documented in previous studies, this study focuses on risk managers and patient safety professionals. More than 70% of participants qualified as burned out. Common sources of stress included social distancing, changing duties, and impacts of the virus. Knowing the sources of stress can guide programs to decrease burnout in this population.

The role of apology laws in medical malpractice.

Ross NE, Newman WJ. J Am Acad Psychiatry Law. Epub 2021 May 21.

Open disclosure of errors and adverse events is increasingly encouraged in healthcare, but clinicians frequently cite fear of malpractice lawsuits as a reason to avoid apologizing for an error. This commentary summarizes the relationship between apologies and malpractice, the emergency of apology laws in the United States, and research exploring the impact of apology laws on malpractice claims and patient outcomes.

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.

Improving Patient Safety with Human Factors Methods.

Armstrong Institute for Patient Safety and Quality. October 11, 15 and 20, 2021.

Human factors engineering (HFE) is a primary strategy for advancing safety in health care. This virtual workshop will introduce HFE methods and discuss how they can be used to reduce risk through design improvements in a variety of process and interpersonal situations.

Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA.

Office of Inspector General. June 2, 2021. Report No. 18-02496-157.

Health systems can exacerbate potential risk for patient harm due to clinician impairment and unprofessional activities. This report examines a long-term situation that, due to failure of reporting and other system issues, enabled over 3,000 diagnostic delay injuries stemming from specimen errors associated with one pathologist.

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.

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