The PSNet Collection

4 actions to reduce medical errors in U.S. hospitals.

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Toussaint JS, Segel KT. Harvard Business Review. April 20, 2022.

The patient safety movement has had mixed results in sustaining improvement and commitment. This commentary discusses strategies to instigate continued energy toward reducing medical error: prioritization of patient safety as a hospital imperative, formation of a National Patient Safety Board, installation of a single national body for incident reporting, and implementation of electronic health record learning systems that flag potential risks.

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Medication/Drug Errors

Anatomy of a medical device recall: How defective products can slip through an outdated system.

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Zipp R. Medical Tech Dive. October 18, 2021.

This article highlights systems influences that detract from the effectiveness of current methods of reporting recalled unsafe medical devices and raising awareness of recalls for clinicians, patients and families. Challenges highlighted include the use of paper-based notification systems and data reporting delays.

Parenteral nutrition safety.

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Mirtallo JM, Ayers P. Pharmacy Practice News. September 7, 2021;48(9):17-20.

Parenteral nutrition (PN) processes contain various steps that are prone to errors resulting in patient harm. This article discusses standardization as a strategy to reduce the potential for missteps and shares resources for process evaluation to improve PN reliability and safety.

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Maternal Safety

Geriatric medication reconciliation in the home setting.

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Taylor K. American Nurse J. 2021;16(7):14-17.

Medication reconciliation reduces the potential for problems in complicated medication regimens. This article shares strategies for reconciling medications for older patients in the home to ensure their medication use is safe and appropriate.

'An ongoing nightmare': people with obesity face major obstacles when seeking medical care.

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Schapiro R. NBC News. June 27, 2021.

System failures cause care delays in a wide range of patient segments. This news story describes barriers to safe, patient-centered care experienced by overweight patients such as bias, ineffective space consideration, and lack of access to screening equipment.

Pandemic imperiled non-English speakers more than others.

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Bebinger M. WBUR and Kaiser Health News. April 27, 2021.

Non-English-speaking patients experience barriers to safely navigating the American healthcare system. This story discusses the impact that language and disparities had on care during the pandemic at one health system, and shares outreach communication and translation strategies to improve care safety.

When machine learning goes off the rails. A guide to managing the risks.

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Babic B, Cohen IG, Evgeniou T, et al. Harv Bus Rev. 2021 January/February;99(1):76-84.

This article discusses how machine learning can create unanticipated risks in the context of health care delivery. The authors summarize areas of concern healthcare leadership should explore when determining the implementation of machine learning in their organizations.

Medicare cuts payment to 774 hospitals over patient complications.

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Rau J. Kaiser Health News. February 19, 2021.

Financial incentives have shown both benefits and limitations in addressing hospital-acquired harm. This news article summarizes an annual tally of hospitals facing Medicare payment reductions for high rates of infections and other preventable hospital-acquired conditions.

When COVID-19 hit, many elderly were left to die.

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Stevis-Gridneff M, Apuzzo M, Pronczuk M. New York Times. 2020;August 8.

Residential care facilities have been challenged by COVID-19. This story examines the weakness of care processes in nursing homes in Europe that have been revealed due to the pandemic. Data gaps, resource allocation choices, and hospital space considerations are noted situations that have resulted in unintended consequences, reducing the safety of care for this at-risk population.

Doctors and dentists still flooding U.S. with opioid prescriptions.

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Mann B. National Public Radio. 2020;July 17.

Despite efforts to reduce opioid prescribing for pain management, physicians and dentists still overprescribe these medications. This news story shares concerns regarding how engrained the reliance on medications for pain management is to the culture of care and its role in opiate dependence and abuse.

‘Last responders’ seek to expand postmortem COVID testing In unexplained deaths.

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Andrews M. Kaiser News Network. May 19, 2020.

Post-mortem examination is an important tool for determining if misdiagnosis occurs. The authors discuss the value of assessing cause of death for patients thought to have died from COVID-19 to understand disease spread and true impact.

Do some surgical implants do more harm than good?

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Groopman J. New Yorker Online. April 13, 2020.

Medical devices support quality of life but must be designed appropriately and managed carefully to ensure safety over time. This feature discusses industry processes that reduce the reliability of surgical implants, including gaps and weaknesses in regulatory oversight.

She hoped to shine a light on maternal mortality among Native Americans. Instead, she became a statistic of it.

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Chuck E, Assefa H. NBC News. February 8, 2020.

Maternal morbidity and perinatal harm can be exacerbated due to implicit bias. This story discusses a case of an American Indian/Alaska Native mother and infants whose deaths may have been preventable had her concerns been more effectively addressed. The situation illustrates conditions in the broader indigenous peoples’ community that indicate a lack of respect and patient-centeredness as factors contributing to poor care.

Preeminent hospitals penalized over rates of patients’ injuries.

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Rau J. Kaiser Health News. January 30, 2020.

Medicare reimbursement restrictions are a controversial stimulus to motivate hospital acquired condition reduction efforts. This news article examines the legacy of the penalties, the data's ability to be effectively applied across various types of institutions, and the lack of direct connection to improvements.

Medical abbreviations that have contradictory or ambiguous meanings.

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Davis N. ISMP Medication Safety Alert! Acute care edition! January 30, 2020.

Multiple organizations have identified using unclear or misleading abbreviations as a threat to patient safety. This article discusses proposed solutions, and provides a rationale for why some solutions may not be feasible.

The role of racism as a core patient safety issue.

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Feeley D, Torres T. Healthcare Executive. 2020;35:58-61.

A variety of biases can reduce the effectiveness and safety of care. This commentary focuses on racial bias and highlights its deleterious impact on maternity care and maternal safety. The authors suggest tactics to improve listening, implicit bias acknowledgement and data standardization as strategies to counteract the trend.

Start the new year off right by preventing these top 10 medication errors and hazards.

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ISMP Medication Safety Alert! Acute care edition. January 16, 2020;26(2):1-6.

Medication errors routinely challenge patient safety. This newsletter article analyzes incidents submitted to the Institute for Safe Medication Practices in 2019 and highlights those that are persistent, yet manageable, if known practice and system changes are implemented.

Mid Staffs scandal: 10 years on, inquiry chair worries NHS staff too scared to speak up.

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Lintern S. The Independent. January 15, 2020.

The Francis report is a primary example of a large-scale examinations of health care system failure. This story highlights that transparency, duty of candor and whistleblowing protections have improved since the report’s release a decade ago but that more work needs to be done to fully embed a culture of safety throughout the United Kingdom National Health Service.

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