The PSNet Collection

Stop using these adult bed rails, warns the Consumer Product Safety Commission.

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Treisman R. National Public Radio. June 6, 2022

Bedrails are used in hospitals and at home to minimize falls despite the potential to contribute to patient harm. This news article summarizes a government recall of ten models of home bed rail devices due to entrapment incidents.

CMS proposal to suppress hospital safety data angers advocates — agency says COVID disruptions, staff shortages hamper ability to fairly score poor performers.

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Clark C. MedPage Today. May 20, 2022.

Public reporting of safety measures is considered a hallmark of health care transparency. This article discusses a proposed change to reporting requirements in the Hospital-Acquired Condition Reduction Program (HACRP). The change would limit the sharing of patient safety indicator data that informs Care Compare and hospital Medicare reimbursements.

Nurse Vaught sentenced for deadly medical error.

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DePeau-Wilson M. MedPage Today. May 13, 2022.

Disciplinary actions against clinicians who err continue despite awareness efforts to inhibit them. This article summarizes reaction to the sentencing of a nurse in a high-profile medication error case. It discusses reverberations throughout healthcare that will affect patient safety efforts.

Woman works to end Black maternal health crisis after daughter dies after giving birth.

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Kindelan K. ABC News. April 14, 2022.

Maternal injury is a persistent challenge in the Black community. This article discusses the case of one mother whose discounted health concerns contributed to diagnostic delay and death. The piece shares social media tools to assist Black mothers in keeping themselves safe during pregnancy and after birth.

Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety.

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ISMP Medication Safety Alert! Acute care edition. April 7, 2022; 27(2):1-6.

The Institute for Safe Medication Practices (ISMP) highlights the negative impacts the recent criminal conviction of a nurse could have for patient safety, including fear of reporting errors and clinicians leaving the profession.

Nurses: Guilty verdict for dosing mistake could cost lives.

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Loller T. Associated Press. March 30, 2022.

Reporting medical errors, learning from them, and improving systems is a cornerstone of improving patient safety. A just culture centers on moving from blaming individuals for medical errors towards a systems-based approach to learning what went on, in order to prevent similar errors in the future. The recent conviction of a nurse involved in the death of a patient has raised concerns that clinicians may not disclose medical errors out of fear of criminal prosecution and conviction.

Dying for Care.

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Stein L, Fraser J, Penzenstadler N et al. USA Today. March 10, 2022.

Nursing home residents, staff, and care processes were particularly vulnerable to COVID-19. This collection of resources examines data and documentation involving one nursing home chain to reveal systemic problems that contributed to failure. It shares family stories that illustrate how COVID affected care in long-term care environments.

A widow’s mission to change NC dental sedation rules.

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Blythe A. NC Health News. March 10, 2022

Patient harm in dentistry is receiving increased attention and scrutiny. This story covers a medication incident and the lack of safety support that contributed to the death of a patient receiving oral surgery. It discusses the response of the patient’s family and their work to change regulations for dental sedation.

Medicare penalizes dozens of hospitals it also gives five stars.

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Rau J. Kaiser Health News. February 8, 2022.

Rating systems face challenges to accurately represent the safety and quality of patient care. This article discusses inconsistent results between national rating systems and those organizations penalized by the Hospital-Acquired Condition Reduction Program though reduction of Medicare payments for hospitals recording certain adverse events.

How nursing homes’ worst offenses are hidden from the public.

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Gebeloff R, Thomas K, Silver-Greenberg J. New York Times. December 9, 2021.

Nursing homes harbor numerous challenges to patient safety and they should be transparently reported and acted upon to ensure improvement. This news investigation discusses a gap in the reporting and inspection of nursing home incidents that undermines the ability of the US nursing home rating system to inform consumer long term care facility choice.

Her husband died by suicide. She sued his pain doctors—a rare challenge over an opioid dose reduction.

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Joseph A. Stat News. November 22, 2021

The opioid epidemic has put regulatory and professional pressures on the tapering of pain medications that have had unintended consequences for patients resulting in harm. This news story discusses how one family used legal means to address systemic gaps and clinical missteps that resulted in patient suicide due to lack of appropriate pain control.

Patients went into the hospital for care. After testing positive there for Covid, some never came out.

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Jewett C. Kaiser Health News. November 4, 2021.

Nosocomial infection is a primary concern due to the COVID pandemic. This news story examines instances when inpatients contracted, and sometimes died of, COVID-19 while receiving care for a different condition. It summarizes the challenges associated with collecting adequate data that completely document nosocomial spread of COVID-19 and its impact on patient outcomes.

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.

How to seek care for non-covid health issues during the pandemic, and why you shouldn’t delay.

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Bever L, Chiu A. Washington Post. September 16, 2021.

Throughout the COVID pandemic, patients have shown reluctance to seek medical care, which contributes to delayed diagnoses and treatments for non-COVID conditions. This news story suggests actions for patients to take to keep themselves safe from harm while accessing care during uncertain times.

Phony diagnoses hide high rates of drugging at nursing homes.

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Thomas K, Gebeloff R, Silver-Greenberg J. New York Times. September 11, 2021.

Nursing home medication misuse is a contributor to resident harm. This story highlights system influences such as staffing shortages, reporting failures and normalization of prescribing behaviors that coincide with the misuse of antipsychotic medications and overdiagnosis of schizophrenia.

A crisis within a crisis.

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Ellis NT, Broaddus A. CNN. August 25, 2021.

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.

Curated Libraries

Maternal Safety

‘He thought what he was doing was good for people.’ Why is it so difficult to prevent unnecessary medical procedures in the U.S. health-care system?

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Outcalt C. The Atlantic. August 2021.

Overuse and unnecessary care lead to serious patient harms and a cascade of negative consequences. This story describes the overuse behavior of one surgeon to illustrate influences contributing to the problem.

The pain was unbearable. So why did doctors turn her away?

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Szalavitz M. Wired Magazine. August 11, 2021.

The opioid epidemic has contributed to uncertainties for pain management patients that result in harm. This article discusses how an endometriosis patient was unable to get prescriptions to manage her pain due to misinformation generated through screening tools designed to identify opioid misuse and inform prescribing decisions.

Use systems redesign and the law to prevent medical errors and accidents.

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Saks MJ, Landsman S. Stat News. August 4, 2021.

This article introduces the systemic task of medical error reduction and discusses the need for a business case, enterprise-wide accountability and legal process change to drive improvement.

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