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Content ArticleClinician burnout in healthcare is a growing area of concern, especially as the COVID-19 pandemic stretches on. Research from the U.S. Department of Veterans Affairs and Regenstrief Institute looked at ways organisations can address burnout.
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Content Article
Is the FDA Failing Women? (September 2021)
Patient Safety Learning posted an article in Women's health
Many devices in current use were marketed before the US Food and Drug Administration (FDA) began regulating devices in 1976. Thus, manufacturers of these devices were not required to demonstrate safety and effectiveness, which presents both clinical and ethical problem for patients, especially for women, as some of the most dangerous devices—such as implanted contraceptive devices— are used only in women. This article from Madris Kinard and Rita F. Redberg investigates whether and to what extent devices for women receive less rigorous scrutiny than devices for men. This article also suggests how the FDA Center for Devices and Radiological Health could more effectively ensure safety and effectiveness of devices that were marketed prior to 1976. -
Content ArticleThis report was submitted to the United States Congress by the Department of Health and Human Services, in consultation with the Agency for Healthcare Research and Quality (AHRQ). It sets out effective strategies to improve patient safety and reduce medical error.
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Content ArticleThis study, published in BMJ Open, seeks to evaluate variation in Illinois hospital nurse staffing ratios. It attempts to determine how higher nurse workloads are associated with mortality and length of stay for patients, and cost outcomes for hospitals. In their conclusion, the authors suggest that if nurses in Illinois hospital medical–surgical units cared for no more than four patients each, thousands of deaths could be avoided, and patients would experience shorter lengths of stay, resulting in cost-savings for hospitals.
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Content ArticleThis report, published by the Agency for Healthcare Research and Quality (AHRQ) in the United States, presents findings from a review of 5,500 patient safety records in which the Covid-19 public health emergency was included as part of the description of the event or unsafe condition. It forms part of a series of Network of Patient Safety Databases Data Spotlight reports.
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Content Article
COVID Nursing and PTSD (December 2021)
Patient Safety Learning posted an article in Blogs
In an article for the Patient Safety Journal, Cassandra Alexander, a nurse, shares what it is like on the front lines and the toll it has taken on her mental health—a deeply personal and painful story, yet a traumatic experience shared by many nurses around the United States. -
Content ArticleIn this article for The Washington Post, Christopher Rowland speaks to Americans with Long Covid about the impact the condition has had on their health, lives and ability to work. He particularly focuses on the experience of Tiffany Patino, who has been left with debilitating symptoms and unable to work. As well as the financial impact of having no income, the article looks at the impact Long Covid has had on her mental health and ability to care for her young son. The author also highlights that health insurance companies are withdrawing support from people with Long Covid as there is little evidence around treatments, and suggests that employers need to take a more flexible approach to allow people with Long Covid to re-enter the labour market.
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Content ArticleThis article in the Journal of Minimally Invasive Gynaecology provides an interpretation of the 2014 US Food and Drug Administration (FDA) statement on power morcellation, a gynaecological procedure in which a device is used to slice up fibroid tissue for extraction through small incisions. Although use of power morcellation makes surgery less invasive, it has been shown to spread cancer if it exists within the patient's tissues. This article looks at the legal impact of the FDA statement, which warns against using laparoscopic power morcellators in the majority of women undergoing hysterectomy or myomectomy for uterine fibroids.
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Content ArticlePatient safety is an integral component of high-quality and effective medical care. The stakes are especially high in oncology, where avoiding errors is imperative to delivering safe and effective radiation therapy, chemotherapy, and other high-risk treatments. Changing paradigms in cancer treatment, including oral chemotherapy, personalised medicine, biosimilars, and immunotherapy, create evolving safety challenges for the oncology community. Moreover, shifting federal healthcare policies could have significant implications for the safety and access to high-quality and effective cancer care for millions of patients with cancer. Challenges and opportunities in ensuring patient access to safe, affordable, and high-quality cancer care remain significant within the policy landscape. To explore current patient safety and access issues in oncology, the National Comprehensive Cancer Network (NCCN) convened the NCCN Policy Summit: Ensuring Safety and Access in Cancer Care in Washington, DC, on June 15, 2017. Oncology stakeholders gathered to discuss pertinent patient safety issues and access implications under the Trump administration, as well as policy and advocacy strategies to address these gaps and build on opportunities moving forward. The programme consisted of presentations and two roundtable discussions with vigorous dialogue and audience comments and questions.
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Content ArticleThis blog by the Institute for Safe Medication Practices identifies ten medication safety concerns in the US from 2021 that still need to be addressed. These concerns are: Mix-ups between the paediatric and adult formulations of the Pfizer-BioNTech COVID-19 vaccines Mix-ups between the COVID-19 vaccines or boosters and the 2021-2022 influenza (flu) vaccines EPINEPHrine administered instead of the COVID-19 vaccine Preparation errors with the Pfizer-BioNTech purple cap or grey cap COVID-19 vaccines Errors and delays with hypertonic sodium chloride Errors with discontinued or paused infusions Infection transmission with shared glucometers, fingerstick devices, and insulin pens Adverse glycaemic event errors Every organisation needs a medication safety officer Increasing error reporting
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Content ArticleThis study in the International Journal for Equity in Health used an online survey to measure and assess relationships between health behaviours and outcomes, and measures of wealth and civic engagement. The relationships found in the survey results support the interrelationships of constructs within the conceptual model. The model can serve as a guide for future equity research, encouraging a more thorough assessment of equity.
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EventuntilAbout 900,000 Americans develop venous thromboembolisms each year, about half of which are healthcare-associated. Up to 70% of these blood clots are preventable, yet fewer than 50% of hospital patients receive appropriate preventive treatment, according to the CDC. During this webinar, two experts will share tools and strategies nursing leaders can use to empower their teams to become VTE prevention champions and achieve sustained quality improvements. Learning points: The cost of VTEs — from patients to providers to financial repercussions Key strategies to enhance compliance and improve outcome quality How to energize and excite your team for long-term success. Register
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Event
The Global Patient Experience Event
Patient Safety Learning posted an event in Community Calendar
untilELEVATE PX is a gathering bringing together the voices of the global community committed to transforming the human experience in healthcare. ELEVATE PX is a dynamic, interactive event connecting the community for learning, support and the sharing of ideas to positively impact the experience in healthcare organisations around the world. Hear inspiring patient, family and leadership perspectives. All keynotes will be live-streamed for virtual participants. Further information and registration -
EventuntilWhat we’re getting wrong about the “Five rights of medication use” and other safety myths Despite decades of focus, medication errors, which result from weak medication systems and human factors, constitute the greatest proportion of total preventable harm. Yet across decades of efforts to improve medication safety, a disproportionate burden continues to be placed on human performance, while examination and focus on improving systems and the cultures in which humans work is often limited and reactive. In recognition of World Patient Safety Day, this free Institute for Healthcare Improvement (IHI) webinar examines how traditional approaches to medication safety continue to impede progress. Interprofessional faculty with expertise in systems thinking and human factors engineering will share insights on reorienting our thinking and approaches to medication safety. This webinar will provide fresh ideas for engaging a cross-disciplinary, systems perspective and harnessing team members in the improvement of systems to support medication safety. What you'll learn Review commonly held myths about humans that limit progress in medication safety, including the “Five Rights of Medication Use.” Discuss how human factors design and interventions support human performance and improvements in medication safety. Identify at least one idea for change that you can consider for improving medication safety in your organization. Register This webinar will take place at 12:00-13:00 ET (17:00-18:00 BST)
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Content ArticleThe number of cyberattacks and information system breaches in healthcare has grown steadily, escalating from isolated incidents to widespread targeted and malicious attacks. In 2022, 707 data breeches occurred in the US, exposing more than 51.9 million patient records, according to data from the Department of Health and Human Services (DHHS). To help healthcare organisations address this growing patient safety concern, The Joint Commission has issued this Sentinel Event Alert that focuses on risks associated with cyberattacks and provides recommendations on how healthcare organizations can prepare to deliver safe patient care in the event of a cyberattack.
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Content ArticleThis toolkit provides information about how the US Department of Health and Human Services Office of the Director General conducted recent medical record reviews to identify patient harm. It outlines the decision criteria for adverse events and describes the methods used in the report, 'Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm' in October 2018, building upon a broader series of reports about adverse events in hospitals and other health care settings.
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Content ArticleCalibration, defined as alignment between a person’s diagnostic accuracy and their confidence in that accuracy, is an essential component of diagnostic excellence. Miscalibration—the misalignment between a person’s diagnostic accuracy and their confidence in that accuracy—can manifest as either overconfidence or underconfidence and can have serious consequences for patient diagnosis. This resource about calibration from the US Agency for Healthcare Research and Quality (AHRQ) is primarily aimed at individual clinicians whose scope of practice includes diagnosis. It focuses on processes involved in making a diagnosis and the outcome of giving an explanatory label to patients after these processes unfold.
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Content ArticleDiagnostic error research has largely focused on individual clinicians’ decision making and system design, largely overlooking information from patients. This article in the journal Health Affairs analysed a unique data source of patient- and family-reported error narratives to explore factors that contribute to diagnostic errors. The analysis identified 224 instances of behavioural and interpersonal factors that reflected unprofessional clinician behaviour, including ignoring patients’ knowledge, disrespecting patients, failing to communicate and manipulation or deception. The authors concluded that patients’ perspectives can lead to a more comprehensive understanding of why diagnostic errors occur and help develop strategies for mitigation. They argue that health systems should develop and implement formal programs to collect patients’ experiences with the diagnostic process and use these data to promote an organisational culture that strives to reduce harm from diagnostic error.
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Content ArticleThis study in the Journal of Medical Virology aimed to assess the extent and the disparity in excess acute myocardial infarction (AMI)-associated mortality during the pandemic, focusing on the outbreak of the Omicron strain. Using data from the US Centers for Disease Control and Prevention's (CDC's) National Vital Statistics System, the authors found that excess death, defined as the difference between the observed and the predicted mortality rates, was most pronounced for the 25–44 years age group. Excess deaths ranged from 23%–34% for the youngest compared to 13%–18% for the oldest age groups. The trend of mortality suggests that age and sex disparities have persisted even through the Omicron surge, with excess AMI-associated mortality being most pronounced in younger-aged adults.
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Content ArticleIncreasing adverse events, hospital-associated infections, and other harm to patients have compounded and now fuel the call for the formation of a national patient safety board in the USA. But, with so many established health entities already within the government, will adding one create more complexities than it will oversight? A bill introduced in the House in December 2022 proposes such a body loosely modelled off the National Transportation Safety Board. The group behind the efforts for the board's creation note in a document that it still would not be the "sole solution" needed to properly address patient safety issues nationally, but rather is designed to "augment" the work of other federal agencies and patient safety organisations. The bill proposes that it would not be necessary to identify providers in reports that the board would investigate, and some patient safety experts say this is not the right approach, noting that it would not provide the accountability necessary — particularly since the board would be nonpunitive to begin with. But others argue that this structure could help promote voluntary reporting for more data collection. Three patient safety professionals shared their takes in Becker's Hospital Review.
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Content ArticleThere are signs that some US healthcare organisations are scoring some successes in addressing the worker morale and retention crisis. But data from Press Ganey surveys shows that there is a widening gap between the most- and least-successful organisations. This article draws lessons from the former. It discusses three key elements needed to engage workers, make them more resilient, and make them feel more aligned with their leaders.
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Content ArticleGenerative AI is being heralded in the medical field for its potential to ease the burden of medical documentation by generating visit notes, treatment codes and medical summaries. Doctors and patients might also turn to generative AI to answer medical questions about symptoms, treatment recommendations or potential diagnoses. This article in JAMA Network looks at the liability implications of using AI to generate health information, highlighting that no court in the US has yet considered the question of liability for medical injuries caused by relying on AI-generated information.
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Content ArticleThe Joint Commission's National Patient Safety Goals address patient care and safety to give healthcare organisations a framework for improvement. This article from the University of Southern California takes a look at the current National Patient Safety Goals, the role of healthcare administration in patient safety, strategies to implement safety goals in hospitals and evaluating the effectiveness of safety goals.
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Content ArticleThe Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest database of patient safety event reports in the US. In addition to over 4.5 million acute care reports, the PA-PSRS database contains more than 396,000 long-term care healthcare-associated infection (HAI) reports. This study in Patient Safety aimed to look at trends in HAIs in long term care using data from the PA-PSRS database. The study found that there was an increase in the total number and rate of infections reported to PA-PSRS in 2022.
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Content ArticleUS endocrinologist Richard Plotzker shares a recent experience of buying over-the-counter medication from a grocery store. When he opened the outer packaging, the blister packs were empty apart from one pill in each being resealed by scotch tape. Richard called the manufacturer and returned the medication for investigation. He describes how the incident highlights the need to be vigilant about any unusual appearance in the packaging of medication.
