Buitrago I, Seidl KL, Gingold DB, et al. J Healthc Qual. 2022;44:169-177.
Reducing hospital 30-day readmissions is seen as a way to improve safety and reduce costs. Baltimore City mobile integrated health and community paramedicine (MIH-CP) was designed to improve transitional care from hospital to home. After one year in operation, MIH-CP performed a chart review to determine causes of readmission among patients in the program. Root cause analysis indicated that at least one social determinant of health (e.g., health literacy) played a role in preventable readmissions; the program was modified to improve transitional care.
Johansson H, Lundgren K, Hagiwara MA. BMC Emerg Med. 2022;22:79.
Emergency medical services (EMS) clinicians must decide whether to transport patients to hospitals for emergency care, what level of emergency care they require, or to treat the patient at home and not transport to hospital. This analysis focused on patient safety incidents in Swedish prehospital care that occurred after 2015, following implementation of a protocol allowing EMS clinicians to triage patients to see-and-treat (non-conveyance) or see-and-convey elsewhere. Qualitative analysis of incident reports revealed three themes: assessment of patients, guidelines, and environment and organization. EMS clinicians deviated from the protocol in 34% of cases, putting patients at risk of inappropriate triage to see-and-treat.
Workplace violence in healthcare settings can jeopardize the safety of both patients and healthcare workers. This study found that over half of healthcare workers at one large academic medical center in the United States reported witnessing or experiencing workplace violence. Witnessing or experiencing workplace violence was most common in psychiatric settings and in the emergency department.
Speaking up about concerns is essential to improving safety, but prior research has found that many healthcare workers do not feel comfortable speaking up. In this study, staff members from a disability healthcare organization in Australia responded to a questionnaire regarding organizational identification and culture of safety. Findings highlight the importance of organizational identification and management commitment to safety and psychological safety in promoting speaking up behaviors.
Osei-Poku G, Szczerepa O, Potter A, et al. Patient Safety. 2021;3:6-17.
This mixed-methods study examined the experiences of home healthcare workers in Massachusetts during the COVID-19 pandemic. Participating home care workers noted that the lack of necessary resources (e.g., PPE, testing) and insufficient guidance specific to home care settings made their working conditions feel unsafe.
Prior research found significant confusion among physicians in understanding Physician Orders for Life-Sustaining Treatment (POLST) documents, which can lead to errors. This study found that emergency medical services (EMS) personnel did not exhibit adequate understanding of all POLST or living will documents either. The researchers propose that patient video messaging can increase clarity about treatment, and preserve patient safety and autonomy.
Debesay J, Kartzow AH, Fougner M. Nurs Inq. 2021;29:e12421.
Previous studies have shown that ethnic minority patients are at an increased risk of adverse events. Using critical incidents and provider reflections, this study highlights the challenges faced by healthcare providers when providing care for ethnic minority patients. Similar reflection processes in the work environment may contribute to better coping strategies and improved relationships with ethnic minority patients.
Pohlman KA, Salsbury SA, Funabashi M, et al. Chiropr Man Therap. 2020;28.
This study used the AHRQ Medical Office Survey on Patient Safety Culture to compare patient safety attitudes among chiropractic teaching clinic stakeholders versus academic medicine and chiropractic providers. Chiropractic teaching clinics identified several needs to improve safety culture, including more open communication, staff training, and leadership support in setting safety priorities and decreasing work pressure/pace.
Parush A, Wacht O, Gomes R, et al. J Med Internet Res. 2020;22:e19947.
This study surveyed healthcare professionals in Israel and Portugal to identify key human factors that influence the use of personal protective equipment (PPE) when caring for patients with suspected or confirmed COVID-19. Respondents attributed difficulties in wearing PPE to discomfort, challenges in hearing and seeing, and doffing. Analyses also found an association between PPE discomfort and situational awareness, but this association reflected difficulties in communication (e.g., hearing and understanding speech).
Dzau VJ, Kirch D, Nasca TJ. N Engl J Med. 2020;383:513-515.
This commentary discusses the ongoing impact of COVID-19 on the physical, emotional, and mental health on the healthcare workforce and outlines five high-priority actions at the organizational- and national level to protect the health and wellbeing of the healthcare workforce during and after the pandemic.
A patient with progressive mixed respiratory failure was admitted to the step-down unit despite the physician team’s request to send the patient to the ICU. The case reveals issues of power dynamics, hierarchies, and implicit bias as young female physicians interact with experienced male members in the interdisciplinary team.
This qualitative study sought to assess safety culture among practitioners performing spinal manipulation, mostly chiropractors and physiotherapists. Investigators found that concerns about patient safety were mingled with issues such as competing for business in a fee-for-service model and establishing professionalism when credentials are not consistent. They suggest that a shared understanding of the risks associated with spinal manipulation is needed before incident reporting across multiple practitioner types can be implemented.
Jackson PD, Biggins MS, Cowan L, et al. Rehabil Nurs. 2016;41:135-48.
Transitions are a complicated and vulnerable time for patients, particularly for those with complex care needs. This review examines the literature around care transitions and insights from patient and family advisory councils. The authors recommend standardizing the process for veterans with complex conditions and suggest focus on the use of real-time information exchange, documented care plans, and engaging patients and their families in transitions.
Walley AY, Farrar D, Cheng DM, et al. J Gen Intern Med. 2009;24:1007-1011.
This study found that documentation of a patient's opioid dependence or participation in a methadone maintenance program was suboptimal and created opportunity for potentially unsafe medication interactions.
This study used focus groups, in-depth interviews, and event reporting methods to conclude that Emergency Medical Services (EMS) providers are concerned about existing system issues that require improvement strategies, and about the safety culture in which they work.
Allan J, Ball P, Alston M. Rural Remote Health. 2008;8:835.
Drawing from qualitative interviews with pharmacists and social workers, investigators determined that access to rural health services is affected by individual concerns about privacy and confidentiality, and by the reputation and value system of the health care worker.
Weinberg DB, Gittell JH, Lusenhop W, et al. Health Serv Res. 2007;42:7-24.
The investigators surveyed patients regarding the coordination of their postdischarge care and identified problems with coordination across settings, within settings, and between patients and providers.
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