The PSNet Collection

Differences in hospitals' workplace violence incident reporting practices: a mixed methods study.

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Odes R, Chapman SM, Ackerman SL, et al. Policy Polit Nurs Pract. 2022;23:98-108.

Violence towards healthcare workers can result in harm for staff and patients. This article describes data collected during the first three years of a new statewide incident reporting system, California’s Workplace Violent Incident Reporting System (WVIRS) for Hospitals. Over the three-year period, hospitals reported between 0 and 6 incidents per staffed bed but qualitative analyses revealed variable reporting procedures among hospitals.

Part 2 of the 9th Annual Communication, Apology, and Resolution (CARe) Forum.

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Betsy Lehman Center for Patient Safety. June 2, 2022, 9:30 AM-12:00 PM (eastern).

Communication and resolution programs are a promising strategy for successful management of relationships and actions after medical error occurrence. This session will explore elements of effective discussions after an adverse event through case simulation and dialogue.

At US hospitals, a drug mix-up is just a few keystrokes away.

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Kelman B. Kaiser Health News. April 29, 2022.

Technological solutions harbor unique risks that can result in patient harm. This article shares a response to reports of automated dispensing cabinet (ADC) menu selection limitations that contribute to mistakes. The piece suggests the implementation of a 5-letter search requirement prior to removing a medication from an ADC. It provides an update on industry response to this forcing function recommendation.

The Power of Medical Malpractice Stories to Improve Patient Safety.

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The Collaborative for Accountability and Improvement. May 19, 2022. 2:00 PM (eastern).

The sharing of stories is a key approach for providing information and context to promote change. This webinar will focus on stories drawn from lawsuits, the general patient and family motivation of legal action to minimize the repetition of similar errors, and the ironies involved in the adherence to legal confidentiality that can reduce learning from error.

Improving Patient Safety with Human Factors Methods.

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Armstrong Institute for Patient Safety and Quality. Sept 19, 26, 30, 2022.

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.

Redesigning Event Review with RCA2

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Institute for Healthcare Improvement. Sept 7 - Nov 15, 2022.

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.

Patient Safety Certificate Program.

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American Society for Healthcare Risk Management. Chicago, IL: July 11-16 2022.

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.

How will state medical boards handle cases involving disclosure and apology for medical errors?

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Wojcieszak D. J Patient Saf Risk Manag. 2022;27:15-20.

Open disclosure and apology for errors is recommended in healthcare. In this study, 38 state medical boards responded to a survey regarding disclosure and apology practices after medical errors. Findings suggest that state medical boards have generally favorable views toward clinicians who disclose errors and apologize, and that these actions would not make the clinician a target for disciplinary action; respondents had less favorable views towards legislative initiatives regarding apologies and disclosure.

Frequency and nature of communication and handoff failures in medical malpractice claims.

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Humphrey KE, Sundberg M, Milliren CE, et al. J Patient Saf. 2022;18:130-137.

Poor provider-provider and provider-patient communication can result in significant morbidity and mortality to patients and play a role in malpractice claims. 498 closed malpractice claims were reviewed, with communication failures identified in nearly half. Of the communication errors that involved a failed handoff (47%), the majority could have potentially been prevented with a structured handoff tool.

Increased mortality and costs associated with adverse events in intensive care unit patients.

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Cantor N, Durr KM, McNeill K, et al. J Intensive Care Med. 2022;Epub Mar 3.

Adverse events (AE) may lead to poor patient outcomes as well as increased financial costs. An analysis of more than 17,000 adult intensive care unit patients showed approximately 35% experienced at least one healthcare associated adverse event. Those patients had significantly longer hospital stays, experienced higher rates of in-hospital mortality, and required more invasive intensive care unit (ICU) interventions. Additionally, the total cost of the hospital stay was significantly higher, mostly due to increased length of stay.

A Conversation Among Stakeholders on Medical Malpractice.

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Collaborative for Accountability and Improvement. April 26, 2022.

Communication and resolution programs (CRP) can improve response to patients and families after a harmful medical error. This session examined how silos negatively impact transparency after error and how CRPs can reduce siloed communication. The session features Dr. Jo Shapiro as a panelist.

As a nurse faces prison for a deadly error, her colleagues worry: could I be next?

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Kelman B. Kaiser Health News. March 22, 2022

Criminalization of medical mistakes typifies the blame-focused approach patient safety leaders have worked to reduce in health care. This article covers a high-profile case of medication error involving an automated dispensing system that is ubiquitous in health care.

Making the business case for quality and safety.

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Shah RK, Reinhart R, Cronin J. Otolaryngol Clin North Am. 2022;55:105-113.

Experts have advocated the importance of establishing the business case for safety. This article summarizes approaches to establishing the business case for safety through the use of telehealth case-based vignettes as examples. The authors discuss challenges for establishing a business case for safety and future directions.

Qualitative content analysis: a framework for the substantive review of hospital incident reports.

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Stephens S. J Healthc Risk Manag. 2022;41:17-26.

Effective incident reporting systems play an essential role in identifying and mitigating patient safety threats. This article discusses the need for a standardized approach to incident report analysis and how qualitative content analysis can support incident analysis and help identify risk mitigation strategies, performance improvement initiatives, and educational opportunities for healthcare workers.

2022 IHI Patient Safety Congress

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Institute for Healthcare Improvement. Sheraton Dallas Hotel, 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. Dr. Hardeep Singh and Dr. Eric Thomas are among the keynote speakers. Sessions will take place in-person and virtually.

Diagnostic Error in Medicine 15th International Conference.

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Society to Improve Diagnosis in Medicine. Minneapolis, MN, October 16-18, 2022.

Diagnostic error reduction continues to gain momentum in the research and frontline patient safety communities. This in-person conference will focus on the theme, "The Future of Diagnosis".

Physician liability in the age of data reliance and errors.

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Montesantos L. Ann Health Law Life Sci. 2022;31(Spring):179-215.

Health information technologies (HIT) and advanced learning systems, if poorly designed, used, maintained, integrated, or accessed, harbor the potential for failure across the systems they support. This legal discussion argues for federal standards to establish levels of accountability for physicians who use HIT systems and assign liability, should use result in patient harm.

Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020.

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Washington, DC: VA Office of the Inspector General; February 17, 2022. Report No. 21-01506-76.

Patient suicide is a reoccurring sentinel event that is a challenge for the veteran’s health care community. This report shares the results of 36 unplanned inspections at United States Veterans Affairs facilities. While the inspections found general guidance compliance to be in place, weaknesses in required patient follow-up, staff training and outreach activities were flagged as areas in need of targeted improvement to enhance patient safety.

Diversion is a Threat to Patient Safety: Adopting Best Practices.

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Institute for Safe Medication Practices. April 6, 2022.

Drug diversion can result in patient harm due to reduced medication availability, impaired clinician performance, and loss of trust. This webinar discussed the impact of drug diversion at a system level and outlined steps an organization can take to minimize this risk through workplace health strategies and stewardship programs.

Patient safety assurance in the age of defensive medicine: a review.

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Shenoy A, Shenoy GN, Shenoy GG. Patient Saf Surg. 2022;16:10.

Defensive medicine refers to clinician behaviors with the intent to avoid malpractice risk due to care omissions. This article provides an overview of defensive medicine and its relationship to the taxonomies of medical errors and the risks that defensive medicine places on patients, hospital administrators, and systems, as well as clinicians.

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