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 352

This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to compile the ‘best possible medication history’, and how pharmacy staff roles and responsibilities can reduce medication errors.

Weston M, Chiodo C. AORN J. 2022;115:569-575.
Unintentionally retained foreign objects can be exacerbated by fatigue, distractions, and communication errors. This article highlights the importance of effective teamwork, high reliability orientation, and standardized surgical count methods to minimize the persistent problem of retained surgical items.

Moss LD. Clinical Advisor. June 29, 2022.

Health disparities perpetuated by structural racism degrade patient safety. This article discusses the influence of implicit biases on care delivery and highlights the increased interest and research being generated to improve understanding and initiative design to reduce the impact of implicit bias on care.

Villarosa L. New York, NT: Doubleday: 2022. ISBN 9780385544887. 

Health inequities are receiving increased attention as a patient safety issue. This book examines the persistent problem of systemic racism on the health of Black patients. It summarizes the evidence on how racism affects health care and discusses strategies for improvement such as reducing gaps in implicit bias content in curriculum.

Remle Crowe, PhD, NREMT, is the Director of Clinical and Operational Research at ESO. In her professional role, she provides strategic direction for the research mission of the organization, including oversight of a warehouse research data set of de-identified records (the ESO Data Collaborative). We spoke with her about how data is being used in the prehospital setting to improve patient safety.

Chicago, IL: Harpo Productions, Smithsonian Channel: May 2022.

The COVID-19 pandemic revealed the impact of racial disparities and inequities on patient safety for patients of color. This film shares stories of families whose care was unsafe. The cases discussed highlight how missed and dismissed COVID symptoms and inattention to patient and family concerns due to bias reduces patient safety.

Institute for Healthcare Improvement. Sept 7 - Nov 15, 2022.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.
Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.

Collaborative for Accountability and ImprovementApril 26, 2022.

Communication and resolution programs (CRP) can improve response to patients and families after a harmful medical error. This session examined how silos negatively impact transparency after error and how CRPs can reduce siloed communication. The session features Dr. Jo Shapiro as a panelist.

ISMP Medication Safety Alert! Acute care edition. February 24, 2022; 27(4):1-5; March 10, 2022; 27(5):1-5.

Disrespect for co-workers, peers, and patients degrades safety in the care environment. Part I of this article series summarizes results from a 2021 survey as the latest installment of a long-standing examination of the prevalence of disrespectful behaviors. The results found that poor behaviors are common, a wide array of  unprofessional behaviors are encountered in the workplace, and how they affect safety. Part II shares strategies to decrease the presence and impact of disrespectful behaviors in health care which include creation of confidential reporting systems and support structures.
Vela MB, Erondu AI, Smith NA, et al. Annu Rev Public Health. 2022;43:477-501.
Implicit biases among healthcare providers can contribute to poor decision-making and impede safe, effective care. This systematic review assessed the efficacy of interventions designed to reduce explicit and implicit biases among healthcare providers and students. The researchers found that many interventions can increase awareness of implicit biases among participants, but no intervention achieved sustained reduction of implicit biases. The authors propose a conceptual model illustrating interactions between structural determinants (e.g., social determinants of health, language concordance, biased learning environments) and provider implicit bias.
Schiff GD, Volodarskaya M, Ruan E, et al. JAMA Netw Open. 2022;5:e2144531.
Improving diagnosis is a patient safety priority. Using data from patient safety incident reports, malpractice claims, morbidity and mortality reports, and focus group responses, this study sought to identify “diagnostic pitfalls,” defined as clinical situations vulnerable to errors which may lead to diagnostic errors. The authors identified 21 generic diagnostic pitfall categories involving six different aspects of the clinical interaction – diagnosis and assessment, history and physical, testing, communication, follow-up, and other pitfalls (e.g., problems with inappropriate referral, urgency of the clinical situation not appreciated). The authors suggest that these findings can inform education and quality improvement efforts to anticipate and prevent future errors.
Wells HJ, Raithatha M, Elhag S, et al. BMJ Open Qual. 2022;11:e001551.
Use of personal protective equipment is necessary to reduce the spread of infectious diseases, such as COVID-19, in healthcare settings. The alertness levels of ICU staff who regularly wore full personal protective equipment (FPPE), i.e., respirator mask, body covering suit, visor, gloves, and hat, were tested when not wearing FPPE and after two hours wearing FPPE. Results show health care worker alertness can be negatively impacted by wearing FPPE for as little as two hours.
Gibson BA, McKinnon E, Bentley RC, et al. Arch Pathol Lab Med. 2022;146:886-893.
A shared understanding of terminology is critical to providing appropriate treatment and care. This study assessed pathologist and clinician agreement of commonly-used phrases used to describe diagnostic uncertainty in surgical pathology reports. Phrases with the strongest agreement in meaning were “diagnostic of” and “consistent with”. “Suspicious for” and “compatible with” had the weakest agreement. Standardized diagnostic terms may improve communication.
Vo J, Gillman A, Mitchell K, et al. Clin J Oncol Nurs. 2021;25:17-24.
Racial and ethnic disparities in healthcare can affect patient safety and contribute to adverse health outcomes. This review outlines the impact of health disparities and treatment decision-making biases (implicit bias, default bias, delay discounting, and availability bias) on cancer-related adverse effects among Black cancer survivors. The authors identify several ways that nurses may help mitigate health disparity-related adverse treatment effects, such as providing culturally appropriate care; assessing patient health literacy and comprehension; educating, empowering, and advocating for patients; and adhering to evidence-based guidelines for monitoring and management of treatment-related adverse events. The authors also discuss the importance of ongoing training on the impact of structural racism, ways to mitigate its effects, and the role of research and implementation to reduce implicit bias.
Rosenthal CM, Parker DM, Thompson LA. JAMA Pediatr. 2022;176:119-120.
The care of child abuse victims is affected by resource, racial and infrastructure challenges. This commentary describes how the systemic weaknesses catalyzed by poor data collection approaches contribute to misdiagnosis and suggests that successes be mined to minimize the proliferation of continued disparities in this patient population.