The PSNet Collection

Provider implicit bias: bringing awareness to clinical practice.

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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.

Antifatness in the surgical setting.

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Andreou A. Scientific American. May 26, 2022.

Negative comments and attitudes indicate a lack of professionalism that can affect patient care. This article shares concerns about surgeon biases toward patients who are overweight and calls for clinicians to recognize the problem and address it.

‘Almost like malpractice’: to shed bias, doctors get schooled to look beyond obesity.

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Sausser L. Kaiser Health News. May 24, 2022.

Lack of education contributes to misunderstandings and unhelpful preconceptions. This article discusses biases affecting the care of patients who are overweight. It introduces an educational effort to raise awareness of potential diagnostic and treatment actions affected by clinician bias to decrease safety for this patient population.

Are you well positioned to resolve conflicts with the safety of an order? Learning from a physician’s homicide trial and the firing of multiple healthcare workers.

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ISMP Medication Safety Alert! Acute care edition. May 19, 2022;27(10):1-5.

Challenging authority can be difficult but necessary in risky situations. This article examines a serial euthanasia overdose case and how the individuals interfacing with the physician involved sensed the medications ordered were inappropriate, yet said nothing. The piece discusses organizational and individual steps to encourage raising concerns in an appropriate and effective manner.

As a nurse faces prison for a deadly error, her colleagues worry: could I be next?

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Kelman B. Kaiser Health News. March 22, 2022

Criminalization of medical mistakes typifies the blame-focused approach patient safety leaders have worked to reduce in health care. This article covers a high-profile case of medication error involving an automated dispensing system that is ubiquitous in health care.

Bias in mental health diagnosis gets in the way of treatment.

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Garb HN. Psyche. March 22, 2022.

A wide array of biases can affect clinical judgement and contribute to diagnostic error. This article discusses the impact of implicit biases, test inaccuracy, and data weaknesses in diagnosis of mental health conditions in both children and adults. The author provides recommendations for clinicians and researchers to reduce the impact of bias on diagnosis.

Addressing intimate partner violence and helping to protect patients.

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Quick Safety. January 18, 2022(63):1-3.

Patients may not always reveal underlying causes of ill health such as alcohol and drug misuse or domestic violence due to embarrassment or shame. This newsletter piece shares recommendations for clinicians to explore the potential of an individual experiencing intimate partner violence to preserve their safety after a medical encounter.

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Medication/Drug Errors

Adverse glycemic events and critical emergencies.

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ISMP Medication Safety Alert! Acute care edition. December 2, 2021;(24)1-4.

Insulin is a high-alert medication that requires extra attention to safely manage blood sugar levels in chronic or acutely ill patients. This alert highlights look-alike/sound-alike packaging, delayed medication reconciliation, and dietary monitoring gaps as threats to safe insulin administration in emergencies. Recommendations for improvement are provided for both general in-hospital, and post-discharge care.

When we're all responsible for a patient's death, no one is.

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Prasad V, Medpage Today. November 16, 2021.

The issue of system versus individual accountability can challenge the orientation of safety improvement efforts. This opinion piece discusses the importance of physician recognition of decision making mistakes and the downside of the evolution of morbidity and mortality conferences away from that approach.

Disrespectful behavior in healthcare: has it improved? Please take our survey!

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ISMP Medication Safety Alert! Acute care edition. September 9, 2021;26(18);1-5.

Disrespectful behavior is a persistent contributor to failures in medical care. This article summarizes influences that enable the acceptance and perpetuation of unprofessional behaviors and calls for data to assess its presence and impact in health care environments. The deadline for survey participation is now closed.

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.

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ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares reported vaccine errors and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.

Open Notes shines light on errors in patient medical records — will the new rule lead to a flood of correction requests?

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Clark C. MedPage Today. September 14, 2021.

Patients who have access to their records often find errors that need to be corrected. This story highlights recent US policy changes requiring patient access to their records and explores the impact that requests for changes could have on getting records fixed to ensure accurate information is available to inform future care decisions.

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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.

Drug shortages amid the COVID-19 pandemic.

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Bookwalter CM. US Pharmacist. 2021;46(2):25-28.

COVID-19 has increased uncertainties in sectors across health care. This article discusses a variety of supply-chain factors that impact medication availability. The author suggests roles for pharmacists in antibiotic stewardship and policy implementation to manage shortages safely.

Start the year off right by preventing these top 10 medication errors and hazards from 2020.

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ISMP Medication Safety Alert! Acute care edition. January 27, 2021;26(2).

Medication safety is challenged by both persistent problems and emerging situations. This article summarizes reports of errors submitted voluntarily to the Institute for Safe Medication Practices (ISMP) in 2020. The set list includes both pandemic-related hazards and common problems such as use of abbreviations and opioid-naïve patient prescribing.

Not ‘just depression.’ She seemed trapped in a downward mental health spiral. The real cause was a profound shock.

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Boodman SG. Washington Post. January 23, 2021.

Misdiagnosis can perpetuate over a long period and delay a correct course of treatment. This news feature shares an example of depression misdiagnosis that masked the true problem of a neurological tumor manifesting in what was seen and treated as a psychological condition.

Learning from errors with the new COVID-19 vaccines.

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ISMP Medication Safety Alert! Acute Care Edition. January 14, 2021;26(1);1-5.

Learning from error rests on transparency efforts buttressed by frontline reports. This article examined reports of COVID-19 vaccine errors to highlight common risks that are likely to be present in a variety of settings and share recommendations to minimize their negative impact, including storage methods and vaccination staff education.

A night in the hospital, from both ends of the stethoscope.

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Ofri D. New York Times. January 5, 2021.

Physicians have unique perspectives when exposed to health care delivery problems as patients themselves or as caregivers. This news story shares the author’s frustrations with the system of care observed during an overnight visit at the bedside of her daughter awaiting an emergency appendectomy. Her experience underscored the value of patients and families engaging in the safety of actions clinicians take when providing care.

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