The PSNet Collection

Adverse Health Events in Minnesota: Annual Reports.

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St Paul, MN: Minnesota Department of Health.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.

The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff.

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National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. ISBN: 9780309686259

Nursing homes face significant patient safety challenges, and these challenges became more apparent during the COVID-19 pandemic. This report identifies key issues in the delivery of care for nursing home residents and provides recommendations to strengthen the quality and safety of care delivery, such as improved working conditions, enhanced minimum staffing standards, improving quality measurement, and strengthening emergency preparedness.

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.

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.

COVID-19 Focused Inspection Initiative in Healthcare.

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Occupational Safety and Health Administration. March 2, 2022.

The impact of nursing home inspections to ensure the quality and safety of the service environment is lacking. Weaknesses in the process became more explicit as poor long-term care infection control was determined to be a contributor to the early spread of COVID amongst nursing home residents. This announcement outlines a targeted inspection initiative to assess whether organizations previously sited have made progress toward improving workforce safety.

Caring for Those Who Care: Guide for the Development and Implementation of Occupational Health and Safety Programmes for Health Workers.

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Geneva, Switzerland: World Health Organization and International Labour Organization; 2022. ISBN 9789240040779.

Workforce well-being emerged as a key component of patient safety during the COVID-19 crisis. This report supplies international perspectives for informing the establishment of national regulations and organization-based programs to strengthen efforts aiming to develop health industry workforce health and safety strategies.

Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints.

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Washington, DC: United States Government Accountability Office; November 30, 2021. Publication GAO-22-105142.

Patient complaints have the potential to be used for care improvement as they surface problems in health facilities. This report examined complaint response processes in Veterans Affairs nursing homes and found them lacking. Five recommendations submitted to drive improvement underscore the value of adherence to policy and the transfer of complaint experiences to leadership.

National Healthcare Quality and Disparities Reports.

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Rockville, MD: Agency for Healthcare Research and Quality.

In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.

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.

Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings.

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Weenink J-W, Wallenburg I, Leistikow I, et al. BMJ Qual Saf. 2021;30:804-811.

This qualitative study explored the impact of published inspection frameworks on quality and safety in nursing home care, dental care, and hospital care. Respondents noted the importance of the inspection framework design, the role of existing institutional frameworks, and how the frameworks can influence quality improvement across various organizational levels.

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.

Long-term care nurses' experiences with patient safety incident management: a qualitative study.

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Serre N, Espin S, Indar A, et al. J Nurs Care Qual. 2022;37:188-194.

Safety concerns are common in long-term care (LTC) facilities. This qualitative study of LTC nurses explored nurses’ experiences managing patient safety incidents (PSI). Three categories were identified: commitment to resident safety, workplace culture, and emotional reaction. Barriers and facilitators were also discussed.

Cancer diagnoses delayed among prisoners in Washington state.

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Medscape Medical News. May 12, 2021.

Delays and mistakes in health care for distinct patient populations hold improvement lessons for the broader system. This news story highlights problems in correctional system cancer diagnoses and treatment that may indicate other types of prison care delivery problems.

Addressing systemic racism in nursing homes: a time for action.

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Sloane PD, Yearby R, Konetzka RT, et al. J Am Med Dir Assoc. 2021;22:886-892.

Racial bias and racism are increasingly seen as a critical patient safety issue. In this article, the authors outline the components of systemic racism (structural/institutional, cultural, and interpersonal), how they manifest and affect the long-term care system, and the detrimental impact of systemic racism on Blacks during the COVID-19 pandemic.

In U.S. nursing homes, where Covid-19 killed scores, even reports of maggots and rape don’t dock five-star ratings.

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Silver-Greenberg J, Gebeloff R. New York Times. March 13, 2021.

The value of rating systems can be challenged by bias and misinterpretation due to a variety of factors. This article outlines how nursing home patients fell victim to both systemic and care failings in the US nursing homes, yet their facilities still ranked high in a national rating system. The authors discuss failures including the lack of data auditing and a focus on ratings rather than quality.

High nursing staff turnover in nursing homes offers important quality information.

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Gandhi A, Yu H, Grabowski DC. Health Aff (Millwood). 2021;40:384-391.

Prior research has found that high nursing staff turnover is associated with lower patient safety culture. Starting in July 2016, the Centers for Medicare & Medicaid Services (CMS) began collecting daily staffing data for US nursing homes and found that nurse turnover rates were correlated with facility location, for-profit status, Medicaid patient census, and star ratings. This information can be leveraged by policymakers, payers, and healthcare consumers and may incentive efforts to reduce nursing staff turnover.

Improving Diagnosis in Medicine Act of 2020.

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116^th Congress 2d session. December 10, 2020.

The strengthening of diagnostic error research and processes can strategically ensure lasting diagnostic improvement. The ‘‘Improving Diagnosis in Medicine Act of 2020’’ outlines characteristics of a proposed Federal program to enhance agency cooperation and coordination to improve diagnosis in health care by addressing systemic weaknesses, knowledge gaps, and training issues in the workforce.

Nursing homes fined for COVID infection control lapses.

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Jaffe S. Medpage Today. November 25, 2020.

Infection control is a primary safety mechanism that presents challenges for nursing homes. This news story highlights a Centers for Medicare and Medicaid Services program to fine nursing homes for infection control lapses during the COVID pandemic and discusses the potential residual impacts of the strategy.

The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul.

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de Bienassis K, Llena-Nozal A, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 121.

Adverse events in long term care facilities are acerbated due to staffing, training and financial challenges. This report examined the costs of avoidable problems in long term care and suggests prevention strategies that center on workforce skill development and safety culture improvement.

How the pandemic defeated America.

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Yong E. The Atlantic. 2020;September.

This article takes a holistic view of the multiple preventable failures of the U.S. in managing the COVID-19 pandemic, raising several patient safety issues from the metasystems perspective. The piece highlights systemic problems such as lack of transparency, investment in public health and learning from experience.

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