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

Perioperative patient safety recommendations: systematic review of clinical practice guidelines.

Martínez-Nicolas I, Arnal-Velasco D, Romero-García E, et al. BJS Open. 2024;8:zrae143.

Adherence to evidence-based practices and clinical guidelines is essential to the delivery of safe, high quality healthcare. This systematic review of 267... Read More

Pulse oximeters for medical purposes - non-clinical and clinical performance testing, labeling, and premarket submission recommendations.

Food and Drug Administration. January 06, 2025;

Pulse oximeters are known to be less accurate on persons of color, creating the potential for unsafe care. This... Read More

AHRQ announces interest in health services research to reduce emergency department boarding and hospital crowding.

Agency for Healthcare Quality and Research. Special Emphasis Notice. December 20, 2024;Publication No. NOT-HS-25-012.

Emergency department boarding and overcrowding can contribute to unsafe care. This announcement highlights AHRQ’s interest in funding... Read More

Maternal Health Indicators.

Agency for Healthcare Quality and Research. 2024.

All Clinical Areas (16198)

Displaying 1 - 20 of 16551 Results

Study

Perioperative patient safety recommendations: systematic review of clinical practice guidelines.

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Martínez-Nicolas I, Arnal-Velasco D, Romero-García E, et al. BJS Open. 2024;8(6):zrae143.

Adherence to evidence-based practices and clinical guidelines is essential to the delivery of safe, high quality healthcare. This systematic review of 267 clinical guidelines identified 4,666 perioperative patient safety recommendations for adults, with 45% considered strong recommendations. However, the authors noted that only a small subset of recommendations met high methodological standards and identified a gap in pre-admission and post-discharge care recommendations.

Study

High-risk medication errors: insight from the UK National Reporting and Learning System.

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Alrowily A, Alfaraidy K, Almutairi S, et al. Explor Res Clin Soc Pharm. 2025;17:100531.

Errors involving high-risk medications have the potential to cause serious harm or death. In this study, incident reports from the UK's National Reporting and Learning System involving three high-risk medications—opioids, insulin, and anticoagulants—were analyzed to determine the nature and types of errors as well as contributing factors. Around half of errors for each type of medication occurred at administration. 97% of errors resulted in low or no harm. Despite the encouraging results, the authors note the importance of continuing to improve the quality of incident reports to yield better learning opportunities to improve medication safety.

Study

Characteristics and trends of medical diagnostic errors in the United States.

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Ao HS, Matthews T. Patient Safety. 2024;6(1):123603.

Diagnostic errors account for a significant proportion of malpractice lawsuits and payouts. In 20 years of closed malpractice claims, diagnostic errors comprised 26.6% of cases, 39% of which resulted in death. Failure to diagnose and delay in diagnosis were the most common specific allegation types. Overall, diagnosis-related allegations trended downward; however, inpatient allegations trended upward. Payment was higher for men than women, suggesting an area for further research.

Study

What are the unintended patient safety consequences of healthcare technologies? A qualitative study among patients, carers and healthcare providers.

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Abdelaziz S, Garfield S, Neves AL, et al. BMJ Open. 2024;14(11):e089026.

While advanced technologies improve patient safety in many ways, there are often unintended consequences. When patients, carers, and healthcare providers describe potential patient safety consequences of technology in health care, five themes emerge: inequity of access, increased end-user burden, loss of the human element of health care, over-reliance on technology, and unclear responsibilities. A novel finding was the potential "gaming" of technology wherein a patient enters falsified data to suggest a worsening condition and get an earlier appointment, possibly delaying treatment for another patient.

Study

Longitudinal analysis of culture of patient safety survey results in surgical departments.

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Butler LR, Lashani S, Mitchell C, et al. Front Health Serv. 2024;4:1419248.

The Agency for Healthcare Research and Quality Surveys on Patient Safety Culture™ (SOPS®) are used for assessing patient safety culture and can show trends when completed at multiple points in time. This study uses an innovative approach to analyze Hospital SOPS results longitudinally by calculating the difference between positive and negative responses (Delta). Results of the Delta analysis were similar to the traditional scoring method (percent of positive responses) and allowed for a more thorough understanding of survey results.

Study

Interventions to improve timely cancer diagnosis: an integrative review.

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Graber ML, Winters BD, Matin R, et al. Diagnosis (Berl). 2024;Epub Oct 18.

Cancer is one of the "Big Three" misdiagnosis-related harms in malpractice claims. This integrative review of missed opportunities to diagnose cancer identified "closing the loop" as a cross-cutting theme to improve timely diagnosis. Closing the loop includes better communication with the patient at the initial encounter, structured communication between the ordering provider and radiology, and closer follow-up with patients after abnormal test results.

Study

“I had no idea this happened”: electronic feedback on clinical reasoning for hospitalists.

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Kotwal S, Udayappan KM, Kutheala N, et al. J Gen Intern Med. 2024;39(16):3271-3277.

Feedback on the diagnostic process can improve clinical reasoning and improve diagnostic safety. This study evaluated satisfaction with an e-feedback system for hospitalists (focused on care escalation episodes). Satisfaction among participating hospitalists was high. Qualitative analysis of feedback surveys highlighted the value of learning about patient outcomes, detailed feedback, and reflecting on clinical decision-making.

Study

Older adult misuse of over-the-counter medications: effectiveness of a novel pharmacy-based intervention to improve patient safety.

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Gilson AM, Chladek JS, Stone JA, et al. J Patient Saf. 2024;21(1):38-47.

Unintentional misuse (e.g., drug-drug, drug-age interactions) of over-the-counter (OTC) medications can result in significant patient harm, particularly for high-risk populations, such as older adults. In this study, community pharmacies participating in the intervention redesigned pharmacy aisles to support older adults' selection of safe OTC medications (Senior Safe); control pharmacies did not make any design changes. Consumers age 65 or older at participating pharmacies were asked to read a hypothetical health scenario, select an OTC from inside the pharmacy, and then describe how they would use it. Drug-drug and drug-age misuse types were more common at control pharmacies for high-risk medications.

Study

Developing and evaluating large language model-generated emergency medicine handoff notes.

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Hartman V, Zhang X, Poddar R, et al. JAMA Netw Open. 2024;7(12):e2448723.

Suboptimal handoffs are associated with increased risk of adverse events. In this study, a large language model (LLM) was designed and used to draft notes for handoff from the emergency department to inpatient services. Compared to physician-written notes, LLM-generated notes included higher detail but slightly lower usefulness and patient safety scores. None of the LLM-generated handoff notes were considered a critical patient safety risk.

Special or Theme Issue

Psychological Safety in Healthcare Settings.

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Int J Public Health. 2024;69.

The importance of creating healthcare environments that enable concerns to be voiced and support individuals who err is an international concern. This special issue examines a range of elements that impact psychological safety in health care. Articles discuss topics such as peer support, second victims, safety climate, and speaking up.

Commentary

How do we know when we have done enough? Ensuring sufficient patient notification efforts after a large-scale adverse event.

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Alfandre D, Foglia MB, Holodniy M, et al. Jt Comm J Qual Patient Saf. 2024;Epub Nov 5.

While large-scale adverse events (LSAEs) are rare, healthcare organizations must maintain policies on LSAE disclosure (LSAED) should they occur. This article provides an analytic framework for healthcare organizations to consider in the event of an LSAE. The process begins with identification of the LSAE, followed by determination of justifiability of disclosure, determination of requisite effort for notification, and execution of notification plan.

Study

Teaching nursing students the ethical and legal consequences of medical errors: insights from the RaDonda Vaught case using the jigsaw technique.

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Geiselman EL, Opsahl A, Townsend C. J Prof Nurs. 2024;55:105-111.

A just culture ensures that staff feel safe reporting errors without fear of reprisal or retaliation. This article describes an educational activity for nursing students to help them understand the legal and ethical consequences of medical errors and error reporting using the RaDonda Vaught case as an exemplar. After the activity, students reported greater understanding of error reporting, the role of state boards of nursing, system failures, and just culture.

Press Release/Announcement

AHRQ announces interest in health services research to reduce emergency department boarding and hospital crowding.

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Agency for Healthcare Quality and Research. Special Emphasis Notice. December 20, 2024;Publication No. NOT-HS-25-012.

Emergency department boarding and overcrowding can contribute to unsafe care. This announcement highlights AHRQ’s interest in funding research and innovations that address the problem. Care omission, treatment delay, and staff distraction illustrate topics covered by this notice.

Review

Experiences of nurses speaking up in healthcare settings: a qualitative metasynthesis.

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Lee E, De Gagne J C, Randall P S, et al. J Adv Nurs. 2024;Epub Nov 4.

Psychological safety and confidence in speaking up about safety concerns are essential characteristics of a culture of safety. This qualitative metasynthesis reviewed 15 studies to explore nurses’ experiences of speaking up. The analysis identified barriers to speaking up, such as hierarchical structures and poor work environment, as well as factors supporting speaking up, such as interprofessional responsibility and a supportive atmosphere.

Press Release/Announcement

Pulse oximeters for medical purposes - non-clinical and clinical performance testing, labeling, and premarket submission recommendations.

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Food and Drug Administration. January 06, 2025;

Pulse oximeters are known to be less accurate on persons of color, creating the potential for unsafe care. This draft guidance shares regulatory recommendations to improve the performance and appropriate labeling of pulse oximeters to improve its safe use throughout health care. The comment submission process will close on March 10, 2025.

Measurement Tool/Indicator

Maternal Health Indicators.

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Agency for Healthcare Quality and Research. 2024.

Maternal health care faces a variety of patient safety challenges. This set of quality indicators supports the epidemiological or research program use of billing or claims data to measure severe maternal morbidity. The data can be applied to inform the development of population-level improvement strategies and track trends in severe maternal morbidity.

Multi-use Website

World Hand Hygiene Day.

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World Health Organization

This global initiative raises awareness about hand hygiene as a strategy to reduce health care–associated infections. The initiative highlights Save Lives: Clean Your Hands, an annual promotional campaign that takes place on May 5. The theme for 2025 is "It might be gloves. It's always hand hygiene."

Press Release/Announcement

NAM Scholars in Diagnostic Excellence program.

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National Academy of Medicine and the Council of Medical Specialty Societies.

Diagnostic error reduction is gaining momentum as a primary focus of patient safety achievement. This educational program will draw from the 2015 Institute of Medicine Improving Diagnosis in Health Care report to support a multidisciplinary cohort of scholars to advance diagnostic improvement. The applications for the 2025 class are due March 3, 2025.

Book/Report

Hospital Reporting Program: Annual Summary.

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Portland, OR: Oregon Patient Safety Commission.

This site provides data and analysis from two Oregon Patient Safety Commission patient safety initiatives: the Patient Safety Reporting Program (PSRP) and Early Discussion and Resolution (EDR) effort. The latest PSRP report discusses the Commission's collaborative efforts in 2023 to implement changes that modernize their data analysis system and infuse equity across their processes. The 2024 EDR analysis discusses the importance of transparency to motivate progress after a patient safety incident occurs.

Review

The role of AI in detecting and mitigating human errors in safety-critical industries: a review.

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Gursel E, Madadi M, Coble JB, et al. Reliability Eng System Saf. 2025;256:110682.

Artificial intelligence (AI) and machine learning (ML) are being used and tested in numerous ways. This review highlights how they are being used to detect and mitigate human error in safety-critical industries, the limitations and challenges of AI/ML, and insights from the recent literature. Examples from health care include using AI to detect diagnostic errors and combining AI with clinician expertise, with the ultimate decision to follow AI’s suggestion resting with the clinician.

Clinical Areas

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