Clinical Areas

Scroll down to search or browse using Clinical Area if you would like to explore PSNet by the healthcare profession, such as the nurse care or medical specialty, featured in the resources.

Latest by Clinical Areas

Patient death after inadvertent infusion of PRN medication hanging on bedside intravenous (IV) pole.

ISMP Medication Safety Alert! Acute Care. 2024;29(8):1-4.

A multitude of latent and active failures typically contribute to harmful medication errors in hospitals. This article examines a prolonged... Read More

Patient Safety Rights Charter.

Geneva, Switzerland: World Health Organization; April 2024. ISBN: 9789240093249.

High reliability pediatric heart centers: always working toward getting better.

Torzone A, Birely A. Curr Opin Cardiol. 2024;Epub Mar 27.

High reliability organizations can operate in complex, high-risk situations for extended periods without sacrificing safety. This article discusses how high reliability... Read More

Calculating the cost of medication errors: a systematic review of approaches and cost variables.

Ranasinghe S, Nadeshkumar A, Senadheera S, et al. BMJ Open Qual. 2024;13:e002570.

Preventable adverse events can lead to significant excess costs for patients, caregivers, and healthcare systems. This systematic review of 33 studies... Read More

All Clinical Areas (16151)

Displaying 1 - 20 of 16151 Results

Study

Supporting error management and safety climate in ambulatory care practices: the CIRSforte study.

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Müller BS, Lüttel D, Schütze D, et al. J Patient Saf. 2024;Epub Mar 18.

Patient safety in ambulatory care settings is receiving increasing attention. This study evaluated an error management and safety climate intervention implemented across 184 ambulatory practices in Germany. The intervention included email newsletters on error management, e-learning modules to improve team engagement, and interdisciplinary workshops to discuss critical incidents. Survey feedback identified significant improvements in safety climate as well as improvements to incident reporting and learning systems.

Study

Judgment errors in surgical care.

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Marsh KM, Turrentine FE, Jin R, et al. J Am Coll Surg. 2024;238:874-879.

Knowing when judgment errors are more likely to occur can increase surgeons' awareness before, during, and after procedures. This study examined the records of 131 patients with 30-day morbidity or mortality to identify any errors in judgment that may have contributed to harm. Examples of errors in judgment included inappropriate operation, premature discharge, and premature removal of drain. Most errors occurred post-operatively (including after discharge) and in colorectal and hepatobiliary procedures.

Study

Co-worker unprofessional behaviour and patient safety risks: an analysis of co-worker reports across eight Australian hospitals.

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McMullan RD, Churruca K, Hibbert P, et al. Int J Qual Health Care. 2024;36:mzae030.

Unprofessional behavior negatively impacts teamwork, safety culture, and patient safety. This study analyzed 1,310 reports of unprofessional behavior across eight Australian hospitals between 2017-2020. The researchers found that three in ten reports indicated a risk to patient safety, such as interruptions, poor handover communication, and a lack of adherence to hospital policy or protocol.

Study

Paediatric medication incident reporting: a multicentre comparison study of medication errors identified at audit, detected by staff and reported to an incident system.

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Li L, Badgery-Parker T, Merchant A, et al. BMJ Qual Saf. 2024;Epub Apr 15.

Errors and near misses reported to incident reporting systems (IRS) provide valuable information, but studies have shown errors frequently go unreported. In this study of medication errors in two children hospitals, out of 11,302 prescribing errors identified during audit, only 36 had been reported to the IRS; none of the 2,883 administration errors were reported to the IRS.

Commentary

High reliability pediatric heart centers: always working toward getting better.

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Torzone A, Birely A. Curr Opin Cardiol. 2024;Epub Mar 27.

High reliability organizations can operate in complex, high-risk situations for extended periods without sacrificing safety. This article discusses how high reliability concepts can be applied at pediatric cardiac centers to support safe, high-quality care. The authors highlight the importance of interprofessional collaboration, the role of nurses and advanced practice providers, and fostering psychological safety through hierarchy changes.

Review

Calculating the cost of medication errors: a systematic review of approaches and cost variables.

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Ranasinghe S, Nadeshkumar A, Senadheera S, et al. BMJ Open Qual. 2024;13:e002570.

Preventable adverse events can lead to significant excess costs for patients, caregivers, and healthcare systems. This systematic review of 33 studies identified considerable variability in how the costs associated with medication errors are calculated and highlight the need for a validated, standard method for calculating these costs.

Newspaper/Magazine Article

Patient death after inadvertent infusion of PRN medication hanging on bedside intravenous (IV) pole.

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ISMP Medication Safety Alert! Acute Care. 2024;29(8):1-4.

A multitude of latent and active failures typically contribute to harmful medication errors in hospitals. This article examines a prolonged intravenous medication administration error and describes “holes in the Swiss cheese” that enabled the failure. Recommendations for improvement discussed in this article include daily review of medications, look-alike medication management, and infusion line verification.

Book/Report

Patient Safety Rights Charter.

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Geneva, Switzerland: World Health Organization; April 2024. ISBN: 9789240093249.

Patients have the right to expect safe, equitable, high-quality care. This 10-point charter serves to describe the establishment of a broad-based global action plan that enables foundational work to be done in support of patient safety. The right to dignity, competent clinicians, and medical record access are amongst the required elements of the charter.

Study

Missed nursing care in surgical care- a hazard to patient safety: a quantitative study within the inCHARGE programme.

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Edfeldt K, Nyholm L, Jangland E, et al. BMC Nurs. 2024;23:233.

Missed nursing care (MNC) is an indicator of poor quality. This study surveyed nursing assistants (NA) and registered nurses (RN) in three surgical wards in Sweden about the types of and factors associated with MNC. The most frequently missed tasks, reported by both RNs and NAs, included not attending interdisciplinary care conferences and not performing ambulation three times per day. Nearly a quarter of RNs and NAs intended to leave within the year. Given the most frequently endorsed reason for missed nursing care is understaffing, and that a quarter of staff intend to leave within the year, interventions aimed at reducing nurse turnover may reduce missed nursing care.

Study

Safety in teletriage by nurses and physicians in the United States and Israel: narrative review and qualitative study.

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Haimi M, Wheeler SQ. JMIR Hum Factors. 2024;11:e50676.

Teletriage is a component of telehealth wherein patients or their families seek advice on their symptoms and whether, and how urgently, they should seek additional care. This article includes a narrative review and interviews with one American nurse and 15 Israeli pediatric physicians who practice teletriage. Despite the differences between provider profession and health care system, the same essential elements of safe teletriage were identified: specialized clinical training, electronic algorithms and protocols, documentation, and clinical call center standards.

Review

Managers' perceptions of the factors affecting resident and patient safety work in residential settings and nursing homes: a qualitative systematic review.

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Kiljunen O, Savela R‐M, Välimäki T, et al. Res Nurs Health. 2024;Epub Mar 24.

Concerns about resident safety in nursing homes and residential care settings are not new but, but the COVID-19 pandemic brought these concerns to the fore. This review summarizes the managerial perspective of barriers and facilitators to resident safety in long-term care settings. Physical and human resources, and national regulations and networks emerged as pivotal factors in promoting resident safety. The results demonstrate the importance of organizational, not solely individual, support of resident safety work.

Study

Stigmatizing language, patient demographics, and errors in the diagnostic process.

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Brooks KC, Raffel KE, Chia D, et al. JAMA Intern Med. 2024;Epub Apr 15.

Stigmatizing language in electronic health records (EHR) has been shown to negatively impact the quality of patient care and patient hesitancy to seek future care. This study identified that stigmatizing language (questioning of patient credibility, racial or social class stereotyping, expressions of disapproval toward patients, and descriptions of difficult patients) was more common among Black patients than Asian or white, and more common among patients with housing instability. Further work is needed to explore and mitigate these associations.

Study

Department of anesthesiology skilled peer support program outcomes: second victim perceptions.

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Bursch B, Ziv K, Marchese S, et al. Jt Comm J Qual Patient Saf. 2024;Epub Mar 12.

Peer support is a common component of second victim support programs. This study describes second victims' experiences of organizational emotional support before and after introduction of a skilled peer support program (SPSP). Respondents reported that institutional support had increased; they felt like the organization learned from the adverse event to prevent it from recurring.

Study

Healthcare team resilience during COVID-19: a qualitative study.

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Ambrose JW, Catchpole K, Evans HL, et al. BMC Health Serv Res. 2024;24:459.

COVID-19 brought unprecedented challenges to healthcare teams. This study describes factors that contributed to or detracted from healthcare team resiliency. Participants reported increased team cohesion and shared responsibility while also describing the environment as a "pressure cooker." There were also difficulties stemming from gaps in knowledge of reassigned staff, for example, pediatric nurses reassigned to adult wards.

Multi-use Website

Hospital Safety Grade.

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Leapfrog Group

Drawing from data reported by the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services (CMS), this website provides grades for hospitals in the United States based on their safety. The Spring 2024 hospital safety grade results document improvements in healthcare associated infections and patient experience scores. A new data set shares the numbers of hospitals from large metropolitan areas with A grades.

Book/Report

Patient Safety Authority Annual Reports.

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Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2024.

This report summarizes patient safety improvement work in the state of Pennsylvania. It reviews the 2023 activities of the Patient Safety Authority that reflected a strategic emphasis on reporting compliance and data quality. Additional topics covered include patient communication, publication, and learning management system efforts.

WebM&M Cases

Missed Connection: A Case of Inadequate ECG Oversight in Cardiac Surgery

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WebM&M Case April 24, 2024

A 77-year-old man was admitted for coronary artery bypass graft surgery with aortic valve replacement. The operation went smoothly but the patient went into atrial fibrillation with hypotension during removal of the venous cannula. The patient was shocked at 10 Joules but did not convert to sinus rhythm; the surgeon requested 20 Joules synchronized cardioversion, after which the patient went into ventricular fibrillation and was immediately and successfully defibrillated with 20 Joules.

Review

Diagnostic error in mental health: a review.

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Bradford A, Meyer AND, Khan S, et al. BMJ Qual Saf. 2024;Epub Apr 4.

Diagnostic errors in mental health disorders have not yet received the same attention as diagnostic errors in other care settings. This article describes diagnostic pitfalls for common mental health disorders including schizophrenia, anxiety, attention deficit hyperactivity (ADHD), autism spectrum, mood, and bipolar disorders. The authors urge parallel development of interventions to reduce misdiagnosis and estimating error rates.

Study

Comparing hospital leadership and front-line workers' perceptions of patient safety culture: an unbalanced panel study.

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Forbes J, Arrieta A. BMJ Lead. 2024;Epub Apr 3.

Front-line workers (e.g., nurses and physicians) and leaders frequently perceive the safety culture in their organization differently. This study uses data from AHRQ’s Hospital Survey on Patient Safety Culture (HSOPS) V.1.0 from 2008 - 2017 to compare leadership and front-line workers' perceptions of patient safety culture. With responses from 1,810 hospitals and more than 800,000 individuals identified as leaders or front-line workers, results show that leadership has a consistently more positive perception of patient safety culture, particularly on items related to managers.

WebM&M Cases

Managing Care Challenges in a Group Home Setting: Is Staffing Adequate for Unplanned Incidents?

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WebM&M Case April 24, 2024

An elderly patient residing in a group care home, requiring assistance with all activities and having a history of autism-spectrum disorder, experiences fecal leakage issues despite daily medication. During a weekend shift with reduced staffing, a certified nursing assistant (CNA) discovers the patient soiled in bed, necessitating a shower. While attempting to assist the patient, another bowel accident occurs, leading to a fall and head injury when the CNA calls for help.

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