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Hunt J. London, UK: Swift Press; 2022. ISBN: ‎ 9781800751224.

The National Health Service (NHS) has been a leader in patient safety for over 20 years, and yet NHS patients still experience harm. This book shares leadership insights from former NHS Health Secretary Jeremy Hunt intended to help the institution reach a place where zero patient harm will occur. The book discusses primary causes of patient harm, the challenge of organizational culture, solutions supporting improvement, and implementation strategies.
Falk A-C, Nymark C, Göransson KE, et al. Intensive Crit Care Nurs. 2022:103276.
Needed nursing care that is delayed, partially completed, or not completed at all is known as missed nursing care (MNC). Researchers surveyed critical care registered nurses during two phases of the COVID-19 pandemic about recent missed nursing care, perceived quality of care, and contributing factors. There were no major changes in the types of, or reasons for, MNC compared to the reference survey completed in fall 2019.

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.
Abdelmalak BB, Adhami T, Simmons W, et al. Anesth Analg. 2022;Epub May 12.
A 2009 CMS Condition of Participation (CoP) requires that a director of anesthesia services assume overall responsibility for anesthesia administered in the hospital, including procedural sedation provided by nonanesthesiologists. This article reviews the CoP as it relates to procedural sedation, lays out a framework for implementing this role, and describes challenges of implementation in a large health system.
Butler AM, Brown DS, Durkin MJ, et al. JAMA Netw Open. 2022;5:e2214153.
Inappropriately prescribing antibiotics for non-bacterial infections remains common in outpatient settings despite the associated risks. This analysis of antibiotics prescribed to more than 2.8 million children showed more than 30% of children with bacterial infection, and 4%-70% of children with viral infection were inappropriately prescribed antibiotics. Inappropriate prescribing led to increased risk of adverse drug events (e.g., allergic reaction) and increased health expenditures in the following 30 days.
Lefosse G, Rasero L, Bellandi T, et al. J Patient Saf Risk Manag. 2022;27:66-75.
Reducing healthcare-acquired infections is an ongoing patient safety goal. In this study, researchers used structured observations to explore factors contributing to healthcare-related infections in nursing homes in one region of Italy. Findings highlight the need to improve the physical care environment (e.g., room ventilation), handwashing compliance, and appropriate use of antibiotics.

Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022.

Surgical equipment sterilization can be hampered by equipment design, production pressures, process complexity and policy misalignment. This report examines a case of unclean surgical instrument use. It recommends external sterile service assessment and competency review as steps toward improving the reliability of instrument decontamination processes in the National Health Service.

The U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce. Washington DC: Office of the Surgeon General; May 2022.

Health care staff and clinician wellbeing is known to affect safety and quality. This advisory suggests national priorities to target improvement efforts. Areas of focus include workforce shortages, system inequities and burnout.
Dyrbye LN, West CP, Sinsky CA, et al. JAMA Netw Open. 2022;5:e2213080.
Burnout is characterized as emotional exhaustion, depersonalization, and decreased sense of accomplishment at work which results in overwhelming negative emotions. Earlier studies have focused on the association of burnout with the electronic medical record and the COVID-19 pandemic, among others. This study focused on the association of physician burnout and mistreatment by patients, families and visitors. Survey respondents reported experiencing mistreatment (e.g., racially or ethnically offensive remarks) and discrimination (e.g., patients or families refusing to allow the physician to provide treatment based on their gender, race, or ethnicity) in the past year. Experiencing mistreatment or discrimination was associated with burnout.
Massart N, Mansour A, Ross JT, et al. J Thorac Cardiovasc Surg. 2022;163:2131-2140.e3.
Surgical site infections and other postoperative healthcare-acquired infections (HAIs) can lead to significant patient morbidity and mortality. This retrospective study examined the relationship between HAIs after cardiac surgery and postoperative inpatient mortality. Among 8,853 patients undergoing cardiac surgery in one academic hospital in France, 4.2% developed an HAI after surgery. When patients developing an HAI were matched with patients who did not, the inpatient mortality rate was significantly greater among patients with HAIs (15.4% vs. 5.7%).
Politi RE, Mills PD, Zubkoff L, et al. J Patient Saf. 2022;Epub Apr 30.
Delays in diagnosis and treatment can lead to poor outcomes for patients. Researchers reviewed root cause analysis (RCA) reports to identify factors contributing to delays in diagnosis and treatment among surgical patients at the Veterans Health Administration. Of the 163 RCAs identified, 73% reflected delays in treatment, 15% reflected delays in diagnosis, and 12% reflected delays in surgery. Policies and processes (e.g., lack of standardized processes, procedures not followed correctly) was the largest contributing factor, followed by communication challenges, and equipment or supply issues.

National Steering Committee for Patient Safety. Boston, MA: Institute for Healthcare Improvement; May 2022.

Leadership commitment is crucial to attaining sustainable improvement in patient safety. This “Declaration to Advance Patient Safety” call-to-action shares three steps to motivate work toward implementing change to enhance safe care. First, commit to a national plan for improvement. Second, identify and empower a senior leader and team to assess an organization’s existent safety status. Third, devise plans to measure, design, implement, and support adverse event reduction initiatives.
Rotenstein LS, Melnick ER, Sinsky CA. JAMA. 2022;327:2079-2080.
Clinician well-being is increasingly seen as a quality and safety issue. This commentary discusses how systemic efforts must be built to enhance occupational well-being among clinicians. This approach discussed should consider both human factors and organizational design strategies to reduce burnout, cognitive overload, process frustration, and technology use.

Toussaint JS, Segel KT. Harvard Business Review. April 20, 2022.

The patient safety movement has had mixed results in sustaining improvement and commitment. This commentary discusses strategies to instigate continued energy toward reducing medical error: prioritization of patient safety as a hospital imperative, formation of a National Patient Safety Board, installation of a single national body for incident reporting, and implementation of electronic health record learning systems that flag potential risks.

Geneva, Switzerland; World Health Organization; May 5, 2022.

Healthcare-acquired infection is a persistent systemic problem. This report recaps the universal status of infection prevention and control (IPC) programs and highlights the influence of nosocomial infection on care provision and public health. The examination states that concerning IPC disparities exist in low-income countries. It reviews the impact of poor infection control, cost-effectiveness of existing efforts, and recommendations to improve and sustain IPC efforts worldwide.

Ehrenwerth J. UptoDate. May 25, 2022.

Operating room fires are never events that, while rare, still harbor great potential for harm. This review discusses settings prone to surgical fire events, prevention strategies, and care management steps should patients be harmed by an operating room fire.
Halverson CC, Scott Tilley D. Nurs Forum. 2022;57:454-460.
Nursing surveillance is an intervention for maintaining patient safety and preventing patient deterioration. This review builds on the earlier nursing surveillance concept to reflect technological advancements, such as early warning systems, since the intervention was first proposed. Attributes (e.g., systematic processes and coordinated communication) and antecedents (e.g., sufficient nurse education and staffing) associated with nursing surveillance are described, along with a presentation of cases to illustrate the concept.
Odes R, Chapman SM, Ackerman SL, et al. Policy Polit Nurs Pract. 2022;23:98-108.
Violence towards healthcare workers can result in harm for staff and patients. This article describes data collected during the first three years of a new statewide incident reporting system, California’s Workplace Violent Incident Reporting System (WVIRS) for Hospitals. Over the three-year period, hospitals reported between 0 and 6 incidents per staffed bed but qualitative analyses revealed variable reporting procedures among hospitals.
Sittig DF, Lakhani P, Singh H. J Am Med Inform Assoc. 2022;29:1014-1018.
Transitions from one electronic health record (EHR) system to another can increase the risk of patient safety events. Using the principles of requisite imagination, this article outlines six recommendations for safe EHR transitions through proactive approaches, process improvement and support for healthcare workers.
Trbovich PL, Tomasi JN, Kolodzey L, et al. Pediatr Crit Care Med. 2022;23:151-159.
Intensive care units (ICU) are high-risk environments. Based on direct observations, these researchers identified 226 latent safety threats affecting routine care activities in pediatric ICUs. Findings indicate that threats persist regardless of whether individuals comply with or deviate from policies and protocols, suggesting the need for targeted interventions beyond reinforcing compliance.