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 694

Tahir D. Kaiser Health News. September 26, 2022. 

Negative patient representations in medical records perpetuate stereotypes that can affect care over time. This story discusses how written notes using stigmatizing language reflect bias and physician disrespect that serve as clues to misdiagnosis. Black patients and those patients named as difficult were particularly vulnerable to damaging representation in notes.
Clayton DA, Eguchi MM, Kerr KF, et al. Med Decis Making. 2022;Epub Sep 20.
Metacognition (e.g., when one reflects on one’s own decision and decision making) is an approach to reducing diagnostic errors. Using data from the Melanoma Pathology Study (M-PATH) and Breast Pathology Study (B-PATH), researchers assed pathologists’ metacognition by examining their diagnostic accuracy and self-confidence. Results showed pathologists with increased metacognition sensitivity were more likely to request a second opinion for incorrect diagnosis than they were for a correct diagnosis.

President’s Council of Advisors on Science and Technology. Washington, DC: White House; September 21, 2022.

National efforts are required to adjust the health care system and embed safety in programs and processes. Speakers participating in this webinar discussed the impact of errors on families, adverse event prevalence, aviation safety lessons, nursing’s improvement role, the current state of patient safety and what needs to be done to reduce the impact and associated cost of harm.
Ayalew MB, Spark MJ, Quirk F, et al. Int J Clin Pharm. 2022;44:860-872.
Patients with diabetes, particularly those taking multiple medications, are at increased for medication adverse events. In this review of nearly 200 studies of potentially inappropriate prescribing (PIP) for patients with diabetes, several types of PIPs occurred: contraindication, omission, incorrect dosing, drug-drug interaction, inappropriate drug selection, and unnecessary drug therapy.

Safer Care for All. London, England:  Professional Standards Authority for Health and Social Care; 2022.

Dedicated leadership is an important component to examine and address challenges to safety across a system. This report outlines a process to reduce the complexity of care across the United Kingdom through the establishment of offices to address inequity, emerging risk regulation, workforce issues, accountability, and lack of trust in the system.
Boisvert S. J Healthc Risk Manag. 2022;Epub Aug 16.
Social determinants of health (SDOH) are non-medical factors that impact a person’s health and well-being. This commentary presents ways that risk managers can improve equity and patient safety by addressing two SDOH: health literacy and discrimination. The author recommends using existing risk management tools (e.g., error reporting, data collection) to develop strategies to address the negative impacts of SDOH.

Rockville, MD: Agency for Healthcare Research and Quality; September 2022. AHRQ Publication No. 22-0026-3-EF.

Correct consideration of the likelihood that a patient may have a potential disease guides each level of diagnostic decision making; misjudgments can be fatal. This issue brief introduces an information-focused framework to examine how clinicians determine probability and discusses educational avenues for enhancing those skills. The publication is part of a report series on diagnostic safety.
FitzGerald C, Mumenthaler C, Berner D, et al. BMC Med Ethics. 2022;23:86.
Patients with obesity and mental illness face both explicit and implicit bias that negatively impact their healthcare. This study of psychiatric and general internal medicine physicians analyzed implicit and explicit bias towards patients with mental illness and/or obesity. Results varied by specialty, physician age, gender, and experience level.
Suneja M, Beekmann SE, Dhaliwal G, et al. Diagnosis (Berl). 2022;9:332-339.
Delayed diagnosis of infectious diseases can lead to serious patient harm. This survey of over 500 infectious disease clinicians revealed that diagnostic delay often involved diagnoses of infective endocarditis and epidural abscesses. Respondents identified several factors contributing to diagnostic delays including usual clinical presentations and the timing of infectious disease consultations.

NAM’s Action Collaborative on Clinician Well-Being and Resilience. Washington DC, American Association of Medical Colleges or virtual; October 3, 2022, 10:00 AM – 12:00 PM (eastern).

Concerted effort has been undertaken to understand the impact of clinician burnout on patient safety. This webinar will discuss the culmination of a six-year effort to design a national multidisciplinary guidance to address system issues that affect the wellbeing of clinicians.
Keller C. Health Aff (Millwood). 2022;41:1353-1356.
Communication failures due to hierarchy and silos create opportunities for adverse medication and treatment events. This narrative essay discusses gaps in care coordination that contributed to anticoagulant medication errors. The author outlines areas for improvement such as assignment of accountability for error and commitment to the learning health system as avenues for improvement.

Donovan-Smith O. Spokesman-Review. September 11, 2022.

Electronic health record (EHR) system issues degrade the data sharing and communication needed to inform safe patient care. This newspaper feature discusses problems with the new Veterans Affairs EHR system from the patient and family perspective in the context of diagnostic and treatment delay.
Goodwin C, Haas S, Berry WR. BMJ Leader. 2022;Epub Aug 19.
Disruptive behavior includes behaviors that show disrespect for others and impede safe delivery of patient care. This commentary presents a framework for new physician managers to address disruptive behavior modeled after clinical medicine: diagnose, treat, prevent. The authors stress maintaining curiosity during the “diagnostic” phase, careful consideration of “treatment” and follow-up, and “prevention” of future disruption though intentional training and building a culture of safety.

AHA Team Training. October 6 – November 17, 2022.

Despite the recognition that teamwork is essential to safe care, its implementation into established processes can be a challenge. Building on the established TeamSTEPPS® principles, this virtual workshop series focuses on leadership, change management and process integration to enrich organizational efforts to embed effective teamwork into care.
Eggenschwiler LC, Rutjes AWS, Musy SN, et al. PLoS ONE. 2022;17:e0273800.
Trigger tools alert patient safety personnel to potential adverse events (AE) which can then be followed up with retrospective chart review. This review sought to understand the variability in adverse event detection in acute care and study characteristics that may explain the variation. Fifty-four studies were included with a wide range of AEs detected per 100 admissions. The authors suggest developing guidelines for studies reporting on AEs identified using trigger tools to decrease study heterogeneity.
Harris CK, Chen Y, Yarsky B, et al. Acad Pathol. 2022;9:100049.
Physicians, including resident physicians, report safety events at lower rates than nurses and other staff. This study analyzed adverse event and near miss reporting by residents in one American hospital. Although pathology residents accounted for more than 5% of residents in the hospital, they only accounted for 0.5% of all reports.
Adair KC, Heath A, Frye MA, et al. J Patient Saf. 2022;18:513-520.
Psychological safety (PS) is integral to ensuring healthcare workers feel comfortable asking questions and raising patient safety concerns. A novel PS assessment was administered to over 10,000 healthcare workers and support staff in one academic health system. The scale showed a significant correlation with safety culture, especially among those exposed to institutional PS programs (i.e., Safety WalkRounds and Positive Leadership WalkRounds).
Wise J. BMJ. 2022;378:o1974.
Patients can be vulnerable to having concerns dismissed or being gaslighted as to their legitimacy. Implicit biases against women in both clinical and administrative settings are known to foster conditions for unsafe care. This piece defines the use of the term gaslighting and how it can result in diagnostic delay due to a lack of patient-centered communication and respect.
Apodaca C, Casanova-Perez R, Bascom E, et al. J Am Med Inform Assoc. 2022;Epub Aug 19.
Minoritized patients who experience implicit or overt discrimination in healthcare report receiving lower quality of care and may avoid seeking care in the future altogether. In this study, patients who identify as Black, Indigenous, People of Color (BIPOC), and/or Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) describe their experiences of unfair treatment and discrimination in healthcare. Four themes related to immediate reactions and six themes related to long-term coping emerged.
Linzer M, Sullivan EE, Olson APJ, et al. Diagnosis (Berl). 2022;Epub Aug 22.
Challenging working conditions and increased cognitive workload can result in stress and burnout. This article describes a conceptual framework in which working conditions and cognitive workload impact stress and burnout, which, in turn, impacts diagnostic accuracy. Potential uses and testing of the framework are described.