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1 - 20 of 123
Maher V, Cwiek M. Hosp Top. 2022;Epub Jul 20.
Fear of criminal liability may inhibit clinicians from reporting medical errors, thereby reducing opportunities for learning. This commentary discusses recent legal actions brought against clinicians, including Tennessee nurse RaDonda Vaught, and the negative impact such actions may have on the longstanding disclosure movement.
Ibrahim SA, Reynolds KA, Poon E, et al. BMJ. 2022;377:e063064.
Accreditation programs such as The Joint Commission are intended to improve patient safety and quality. Investigators evaluated the evidence base for 20 actionable standards issued by The Joint Commission. Standards were classified by the extent to which they were supported by evidence, evidence quality ratings, and the strength of the recommendation.

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.
Lin M, Horwitz LI, Gross RS, et al. J Patient Saf. 2022;18:e470-e476.
Error disclosure is an essential activity to addressing harm and establishing trust between clinicians and patients. Trainees in pediatric specialties at one urban medical center were provided with clinical vignettes depicting an error resulting in a safety event or near-miss and surveyed about error classification and disclosure. Participants agreed with disclosing serious and minor safety events, but only 7% agreed with disclosing a near miss event. Trainees’ decisions regarding disclosure considered the type of harm, parental preferences, ethical principles, and anticipatory guidance to address the consequences of the error.
Wyner D, Wyner F, Brumbaugh D, et al. Pediatrics. 2021;148:e2021053091.
The dismissal of parental concerns is a known contributor to medical errors in children. This story illustrates how poor communication, lack of respect, and anchoring bias  contributed to failure in the care of a boy. The authors share actions being taken by the hospital involved in the tragedy to partner with the family to improve diagnosis practices throughout their organization.
Brenner MJ, Boothman RC, Rushton CH, et al. Otolaryngol Clin North Am. 2021;55.
This three-part series offers an in-depth look into the core values of honesty, transparency, and trust. Part 1, Promoting Professionalism, introduces interventions to increase provider professionalism. Part 2, Communication and Transparency, describes the commitment to honesty and transparency across the continuum of the patient-provider relationship. Part 3, Health Professional Wellness, describes the impact of harm on providers and offers recommendations for restoring wellness and joy in work.

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.

Patient Safety Movement. October 29, 2021. 

Effective response to medical harm involves a variety of perspectives that are aligned in purpose. This webinar discussed how different stakeholders might view approaches to medical error management. It described how strategies have changed from paternalistic to inclusive processes that consider the impact of mistakes on patients and families and the role of communication is key to achieving fair and honest resolution to adverse incidents.
Elwy AR, Maguire EM, McCullough M, et al. Healthc (Amst). 2021;8:100496.
Disclosure of medical errors is supported by both patients and providers. Following the implementation of the Veterans Health Administration’s policy on disclosing medical errors to patients and their families, it was necessary to determine the effects of implementation (or not) of this policy. This article describes the development, implementation, and sustainment of an error disclosure toolkit for use across the VA system.

Ross NE, Newman WJ. J Am Acad Psychiatry Law. Epub 2021 May 21.

Open disclosure of errors and adverse events is increasingly encouraged in healthcare, but clinicians frequently cite fear of malpractice lawsuits as a reason to avoid apologizing for an error. This commentary summarizes the relationship between apologies and malpractice, the emergency of apology laws in the United States, and research exploring the impact of apology laws on malpractice claims and patient outcomes.

Rosen M, Ali KJ, Buckley BO, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2021. AHRQ Publication No. 20(21)-0040-5-EF.

The mindset on diagnostic error improvement has gone from a focus on individual skills to that of system factors. This issue brief highlights the influence health system executives have on amending the care environment to facilitate the most effective environment for diagnostic accuracy. This is part of a publication series examining diagnostic improvement across health care.

Famolaro T, Hare R, Thornton S, et al. Surveys on Patient Safety CultureTM (SOPSTM). Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0034.

A vibrant culture of safety is critical to achieving high reliability in health care. Ambulatory practices with weaker safety cultures can experience problems in teamwork, diagnosis, and staff turnover. The AHRQ Medical Office Survey on Patient Safety Culture was designed to evaluate safety culture in outpatient clinics. The 2020 comparative database report assessed 10 safety culture domains in 1,475 medical offices. Respondents reported effective patient follow-up practices and scored well on equitable care delivery. Many practices cited time pressure and workload as persistent challenges to safety hazards. Although the practices surveyed are not nationally representative, they do provide a comparative safety culture snapshot for industry assessment. A past WebM&M commentary discussed safety hazards associated with productivity pressures in health care.
Nadkarni A, Levy-Carrick NC, Kroll DS, et al. National Academy of Medicine; 2021.
Communication within teams is central to safe care delivery, crisis management, and staff well-being. This report shares the experience of one hospital that used technology to enhance information-sharing as a strategy to reduce clinician burnout in times of uncertainty and crisis.
Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021;17:30-35.
Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.  

Washington DC; United States Government Accountability Office; November 26, 2020. Publication GAO-21-7SP.

Artificial intelligence (AI) has the potential to enhance the safety and reliability of clinical and administrative functions. This US Government Accountability Office report outlines barriers impacting the widespread use of AI, such as privacy concerns and lack of development transparency. Collaboration and oversight are areas of policy focus highlighted to address these challenges.

Heaven WD. MIT Technology Review. November 12, 2020.

Lack of transparency of research and development processes are thought to undermine the value of artificial intelligence (AI) and trust in its conclusions. This story highlights concerns generated by AI research examining breast cancer screening. The author discusses how the lack of transparency, while understandable due to proprietary concerns, may reduce the safety of the tools as they are tested for use.