Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
1 - 20 of 82

J Med Imaging Radiat Oncol. 2022;66(2):165-309.

Improving patient safety related to radiology and radiation oncology is an ongoing priority. This special issue explores themes related to radiology and radiation oncology, including monitoring and improving quality of care, promoting a culture of safety, and measuring, reporting, and learning from errors.
Gibney BT, Roberts JM, D'Ortenzio RM, et al. RadioGraphics. 2021;41:2111-2126.
Hospitals are increasingly creating and updating their emergency disaster response plans. This guide assists hospital executives, quality & safety professionals, and risk managers by assessing potential hazards or failures in radiology departments in the event of disaster. Disaster planning tools, checklists, and other recommendations are described.  
Yonash RA, Taylor M. Patient Safety. 2020;2:24-39.
Wrong-site surgeries can lead to serious patient harm and are considered never events by the National Quality Forum. Based on events reported to the Pennsylvania Patient Safety Reporting System between 2015 and 2019, the authors identified an average of 1.42 wrong-site surgery events per week and found that three-quarters of events resulted in temporary or permanent patient harm. The authors present several evidence-based strategies to reduce the likelihood of wrong-site surgery, including preoperative and intraoperative verification, site marking, and timeouts.  
Khalatbari H, Menashe SJ, Otto RK, et al. Pediatr Radiol. 2020;50:1409-1420.
This study reviewed safety events involving diagnostic or interventional radiology at one children’s hospital and used data from the root cause analyses to characterize the contributing system failures and key activities and processes. Approximately one-quarter of the safety events were secondary to diagnostic errors.  The most common key processes involved in these events were diagnostic and procedural services, and the most common key activities were interpreting/analyzing and coordinating activities.
Soncrant C, Mills PD, Neily J, et al. J Patient Saf. 2020;16:41-46.
In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.
Stahl JM, Mack K, Cebula S, et al. Mil Med. 2019.
This retrospective study of dental patient safety reports in the military health system demonstrated an increase in reported events, which may reflect improvements in safety culture. Wrong-site surgery was the most common adverse event, suggesting the need to enhance safety practices in dentistry.

Cortegiani A, Gregoretti C, Neto AS, et al; LAS VEGAS Investigators, PROVE Network, Clinical Trial Network of the European Society of Anaesthesiology. Br J Anaesth. 2019;122:361-369.

This study found that patients undergoing surgery at night were more likely to develop intraoperative adverse events, even after adjustment for patient and procedural characteristics. The observed increase in postoperative pulmonary complications was explained by the type of surgery and underlying patient characteristics. This study adds to the body of evidence on risks associated with care outside of usual working hours.
Ogunyemi D, Hage N, Kim SK, et al. Jt Comm J Qual Patient Saf. 2019;45:423-430.
The rise in maternal morbidity and mortality is one of the most pressing patient safety issues in the United States. Formal debriefing after adverse events is an important method for analyzing and improving safety. In this study, an academic hospital adopted a systems-based morbidity and mortality conference model to review cases of serious maternal harm and implemented several safety measures (including teamwork training) to address issues that were identified through structured review.
Slomski A. JAMA. 2019;321:1239-1241.
Maternal mortality is a sentinel event that affects mothers and families across a wide range of socioeconomic characteristics. This commentary explores how data collection gaps, medical errors, ineffective treatments, and care coordination weaknesses contribute to preventable maternal death. The author highlights efforts to improve safety in maternity care such as best practice bundles to ensure teams and clinicians are prepared for certain complications.
Young S, Shapiro FE, Urman RD. Curr Opin Anaesthesiol. 2018;31:707-712.
Office-based surgery is increasingly common, despite concerns regarding its safety. This review summarizes the literature on ambulatory surgery outcomes and identified risk factors such as case complexity, patient comorbidities, and anesthesia use. Few studies examined anesthesia use in dental care.
Sangarlangkarn A.
Rigid adherence to protocols may detract from safety when unexpected critical events occur that require deviation from the standard process. This commentary explores insights from a physician, both as a clinician and as a new mother, when health care staff failed to effectively consider patient concerns and knowledge in understanding and treating the cause of postlabor pain. The patient identified the cause and requested appropriate treatment, but nurses consulted protocols for pain after labor and only offered pain medications, which might have exacerbated the problem. The author calls for clinician autonomy to recognize when standardization is not appropriate and how to address individual patient needs.
Siewert B, Brook OR, Swedeen S, et al. Radiographics. 2019;39:251-263.
Raising concerns in real time can prevent adverse events. This review examines human characteristics that affect the ability of health care workers to report safety events in radiology. Barriers to reporting included organizational culture, accountability, communication weaknesses, and authority gradients. The authors suggest tactics at the organizational, leadership, and staff levels to address conditions that deter raising concerns, including use of structured communication methods such as SBAR.
Badgery-Parker T, Pearson S-A, Dunn S, et al. JAMA Intern Med. 2019;179:499-505.
Overuse of unnecessary tests and procedures contributes to patient harm. In this cohort study, researchers found that patients who developed a hospital-acquired condition after undergoing a procedure that most likely should not have been performed had longer lengths of stay than patients who did not develop a hospital-acquired condition.
Gupta A, Jain S, Croft C. JAMA. 2019;321:504-505.
The authors present a case in which an unnecessary procedure was incorrectly performed on a patient who had opted to pursue hospice care. They highlight factors contributing to the error including those related to use of the electronic health record.
Kozhimannil KB. Health Aff (Millwood). 2018;37:1901-1904.
Maternal harm is a sentinel event that is gaining increased attention in both policy and clinical environments. In this commentary, the author relates her family history of maternal morbidity and mortality and advocates for enhancements in collecting data on maternal health outcomes, access to care, understanding of racial disparities, accountability, and listening to patients and families who have been impacted by unsafe maternal care.
Hospitalized in the ICU with hypoxic respiratory failure due to community-acquired pneumonia, an elderly man had increased pulmonary secretions on hospital day 2 for which the critical care provider decided to perform bedside bronchoscopy. Following the procedure, the patient was difficult to arouse, nearly apneic, and required intubation. The care team paused and discovered that after the patient had received 2 mg of intravenous midalozam, his IV line had been flushed with an additional 10 mg of the benzodiazepine, rather than the intended normal saline.
Simons P, Houben R, Reijnders P, et al. J Patient Saf. 2018;14:193-201.
Organizations with robust safety culture, as measured by AHRQ's Hospital Survey on Patient Safety Culture, have improved objective measures of safety. Researchers compared the AHRQ survey to a factorial survey examining safety behavior among employees in a radiotherapy department. The two surveys yielded similar results, while the factorial survey added that staff were more likely to report safety concerns if they caused patient harm.
Neily J, Soncrant C, Mills PD, et al. JAMA Netw Open. 2018;1:e185147.
The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.
Steelman VM, Shaw C, Shine L, et al. Jt Comm J Qual Patient Saf. 2019;45:249-258.
An unintentionally retained foreign object during a surgery or a procedure is considered a never event and can result in significant patient harm. Researchers retrospectively reviewed 308 events involving unintentionally retained foreign objects that were reported to The Joint Commission to better characterize these events, determine the impact on the patient, identify contributing factors, and make recommendations for improving safety.