The PSNet Collection

Fostering ethical conduct through psychological safety.

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Ferrere A, Rider C, Renerte B et al. Sloan Manag Rev. Summer 2022;39-43.

A baseline expectation in a safe organization is that employees feel comfortable and supported when sharing concerns. This article summarizes key results of a large workplace survey to identify cultural elements supporting the psychological safety required to encourage speaking up when ethical or other issues are identified in operations.

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.

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.

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.

Will prosecuting medical errors lead to a culture of silence?

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Fiore K. MedPage Today. March 28, 2022.

Experts are concerned that convictions for medical error have the potential to limit dialogue on the front line about medical mistakes. This article summarizes discussions regarding the verdict to convict a nurse due to a workaround that resulted in a medication error and patient death.

Survey suggests disrespectful behaviors persist in healthcare: practitioners speak up (yet again) – Parts I and II.

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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.

Pointing fingers: verbosity of patient safety narratives is associated with attribution of blame.

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Ackerman RS, Patel SY, Costache M, et al. Anesthesiology News. November 21, 2021.

Blame is known to limit discussions of near-misses and failures, which negatively impacts learning and incident reduction. This article describes work to examine blameful context present in anesthesiology incident documentation, reducing its viability as a successful investigation record. Length of text was identified as an enabler of blameful orientation, and limitations as to word count were one strategy to minimize the use of punitive language.

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.

Curated Libraries

Maternal Safety

Pump up the volume: tips for increasing error reporting and decreasing patient harm.

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ISMP Medication Safety Alert! Acute care edition. August 26, 2021;26(17);1-5.

Error reporting is an essential contributor to system safety improvement. This article examines weaknesses in error reporting behaviors, characteristics of organizations and technologies that facilitate underreporting and ineffective report analysis. The piece shares recommendations to enhance adverse event reporting to support learning.

10 Leadership mindsets for high reliability organizations. How to empower caregivers and engage patients in patient safety.

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Jurecko L. Consult QD. March 16, 2021.

Leadership actions reinforce organizational efforts to enhance health care safety. This article summarizes foundational concepts for leaders to adopt in order to enhance their work toward achieving high reliability. The author suggests that leadership should embrace certain attitudes including blame reduction, complexity consideration and partnering with patients.

Enhancing a culture of safety through disclosure of adverse events.

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Cornelissen C, Call RC, Harbell MW, et al. APSF Newsletter. February 202136(1);25-27

Error disclosure is supported by a robust safety culture and a defined communication and management approach. This article discusses the engagement of anesthesiologists in the disclosure processes to ensure learning, patient centeredness, and care improvement.

Dispensing Errors.

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Phipps D, Ashour A, Riste L, et al. The Pharmaceutical Journal. 2020;305(7943, 7944). November 10, December 1, 2020.

Dispensing mistakes are a common contributor to preventable adverse events in community pharmacies. Part 1 of this two-part series discusses factors that contribute to dispensing errors and summarizes methods for managing risks stemming from missteps. Part 2 focuses on preventing situations that enable errors and the role pharmacists have in minimizing dispensing errors in daily practice.

Workforce safety key to patient safety.

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McGaffigan P, Gerwig K, Kingston MB. Healthcare Executive. 2020 Nov;35(6):48-50.

Health care workforce satisfaction is the responsibility of leadership and it is reliant on the organizational safety culture. This article highlights the importance of worker conditions as a component of safety and summarizes recommendations for keeping workers safe and thriving.

Safety investigations from across the pond: deep learning from England’s Healthcare Safety Investigation Branch (HSIB).

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ISMP Medication Safety Alert! Acute Care Edition. October 8, 2020;25(20):1-4

In-depth investigations provide multidisciplinary insights that inform sustainable improvement opportunities. This newsletter story highlights a drug administration error examination by a dedicated office in the United Kingdom highlight the value of a commitment to deep, non-punitive analysis of patient safety incidents to enable transparency and learning.

A doctor gave me an inept diagnosis for a neurological problem. I should know: I’m a neurologist.

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Horowitz SH. Washington Post. October 4, 2020.

The harm of misdiagnosis can be extended by lack of clinician recognition and acceptance of the error when a patient raises concerns. This news story shares the experience of a physician-patient whose recognition of a diagnostic mistake was initially dismissed. The author defines the repeated lack of organizational willingness to resolve the situation as a normalized deviance in health care.

During the pandemic, aspire to identify and prevent medication errors and to avoid blaming attitudes.

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ISMP Medication Safety Alert! Acute care edition. August 27, 2020;25(17).

The culture of blame is exacerbated by stress, production pressure, and a negative work environment. This article discusses how medication errors that take place during the care of patients with COVID-19 are not being reported by nurses due to lack of time and psychological safety. Recommendations to avoid this situation include heightening prevention efforts by employing tactics such as deployment of huddles and use of pre-mixed medication solutions.

Avoid punitive approach to your safety event reporting,

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Cheney C. HealthLeaders. September 4, 2020.

A blameless approach to error and near miss reporting is foundational to the success of the effort. This article discusses one organization’s persistent challenge with shifting reporting to align with a safety culture. The author describes the importance of staff education and leadership to support the focus of reporting initiatives on the system rather than individuals when failures occur.

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