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 3493
Nanji K. UpToDate. June 23, 2022.
Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical setting and discusses prevention strategies that focus on medication reconciliation, technology, standardization, and institutional change.
Wooldridge AR, Carayon P, Hoonakker PLT, et al. Hum Factors. 2022;Epub Jun 5.
Handoffs between inpatient care settings represent a vulnerable time for patients. This qualitative study explores how team cognition occurs during care transitions and interprofessional handoffs between inpatient settings and the influence of sociotechnical systems, such as communication workflows or electronic heath record-based interfaces) influence team cognition. Participants highlighted how interprofessional handoffs can both enhance (e.g., information exchange) and hinder (e.g., logistic challenges and imprecise communication) team cognition.
Joseph AL, Monkman H, Kushniruk AW, et al. Stud Health Technol Inform. 2022;2022:535-539.
Patient portals allow patients and their caregivers to read clinical notes, view test results, and communicate with their provider, with the goal of improving patient safety. This scoping review found limited evidence of improved patient safety with the use of patient portals. Additionally, the authors found multiple naming conventions, such as patient portal, personal health record, and personal medical record.

Arora V, Farnan J. UpToDate. June 15, 2022.

The change of an inpatient’s location or handoffs between teams can fragment care due to communication, information, and knowledge gaps. This review examines in-patient transition safety issues and summarizes system level, sender, and receiver tactics to reduce patient vulnerability during handoffs.
Alper E, O'Malley TA, Greenwald J. UpToDate. June 15, 2022.
This review examines hospital discharge, details elements of the process that can increase risk of readmission, and reveals interventions to improve safety.
Krenzischek DA, Card E, Mamaril M, et al. J Perianesth Nurs. 2022;Epub Apr 27.
Patients and caregivers are important partners in promoting safe care. Findings from this cross-sectional study reinforce the importance of patients’ perceived roles in ensuring safe surgery and highlight the importance of patient engagement in mitigating surgical site errors.
Doorey AJ, Turi ZG, Lazzara EH, et al. Catheter Cardiovasc Interv. 2022;Epub Apr 14.
Closed loop communication (CLC) ensures a clear transfer of information by having the recipient repeat the order for verification.  In this study, procedures in the cardiac catheterization lab were observed to assess the frequency and accuracy of CLC. Despite three interventions over five years (education, on-going feedback, accountability), CLC remained suboptimal, with both incomplete orders given and incomplete responses.
Jambon J, Choukroun C, Roux-Marson C, et al. Clin Neuropharmacol. 2022;45:65-71.
Polypharmacy in older adults is an ongoing safety concern due to the risk of being prescribed a potentially inappropriate medication or co-prescription of medications with dangerous interactions. In this study of adults aged 65 and older with chronic pain, 54% were taking at least one potentially inappropriate medication and 43% were at moderate or high risk of adverse drug events. Measures such as involvement of a pharmacist in medication review could reduce risk of adverse drug events in older adult outpatients.
Lazzara EH, Simonson RJ, Gisick LM, et al. Ergonomics. 2022;Epub Apr 19.
Structured handoffs support appropriate communication between teams or departments when transferring responsibility for care. This meta-analysis aimed to determine if structured, standardized post-operative anesthesia handoffs improved provider, patient, organizational and handoff outcomes. Postoperative outcomes moved in a generally positive direction when compared with non-standardized handoffs. The authors suggest additional research into pre- and intra-operative handoffs is needed.
McQueen JM, Gibson KR, Manson M, et al. BMJ Open. 2022;12:e060158.
Patients and families are important partners in improving patient safety. This qualitative study explored the experiences of patients and family members involved in adverse event reviews. The authors identified four themes (communication, trauma, learning and litigation) outline eight key recommendations to address these themes by involving patients and families in adverse event reviews.
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.
Joseph K, Newman B, Manias E, et al. Patient Educ Couns. 2022;Epub Apr 26.
Lack of patient engagement in care can place them at increased risk for safety events. This qualitative study explored ethnic minority stakeholder perspectives about patient engagement in cancer care. Focus groups consisting of participants from consumer and health organizations involved in cancer care in Australia identified three themes supporting successful engagement – consideration of sociocultural beliefs about cancer, adaptation of existing techniques tailored to stakeholders (e.g., culturally specific content), and accounting for factors such as cultural competence during implementation.
Molist-Brunet N, Sevilla-Sánchez D, Puigoriol-Juvanteny E, et al. Int J Environ Res Public Health. 2022;19:3423.
Inappropriate prescribing and polypharmacy can place older adults at increased risk for medication-related adverse events. This study found that up to 90% of older adults had at least one inappropriate prescription, regardless of residential setting but medication review resulted in a greater decrease in risk factors for medication-related adverse events (e.g., polypharmacy, therapeutic complexity) among nursing home patients compared to patients living at home.

Järvinen TLN, Rickert J, Lee MJ. Clin Orthop Relat Res. 2013-2022.

This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.
Armstrong Institute for Patient Safety and Quality. June 14 and 16, 2022
Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model. 
Halverson CC, Scott Tilley D. Nurs Forum. 2022;57:454-460.
Nursing surveillance is an intervention for maintaining patient safety and preventing patient deterioration. This review builds on the earlier nursing surveillance concept to reflect technological advancements, such as early warning systems, since the intervention was first proposed. Attributes (e.g., systematic processes and coordinated communication) and antecedents (e.g., sufficient nurse education and staffing) associated with nursing surveillance are described, along with a presentation of cases to illustrate the concept.
White AA, King AM, D’Addario AE, et al. JMIR Med Educ. 2022;8:e30988.
Communication with patients and caregivers is important after a diagnostic error. Using a simulated case involving delayed diagnosis of breast cancer, this study compared how crowdsourced laypeople and patient advocates rate physician disclosure communication skills. Findings suggest that patient advocates rate communication skills more stringently than laypeople, but laypeople can correctly identify physicians with high and low communication skills.

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

Cox C, Fritz Z. BMJ. 2022;377:e066720.

As more patients are gaining access to their electronic health records, including clinician notes, the language clinicians use can shape how patients feel about their health and healthcare provider. This commentary describes how some words and phrases routinely used in provider notes, such as “deny” or “non-compliant”, may inadvertently build distrust with the patient. The authors recommend medical students and providers reconsider their language to establish more trusting relationships with their patients.