Top 5 Articles of 2021


Take a look at the top 5 articles of 2021 from PSA's award-winning journal

As we prepare to launch our third volume, beginning with a special issue dedicated to academic pharmacy on January 12, we invite you to look back with us at some highlights from 2021.

Last year Patient Safety earned three new publication awards, from the National Association of Government Communicators, FOLIO magazine, and the Digital Health Awards. And our audience has grown to 50,000 readers in 150 countries. See what everyone’s talking about: Check out the most popular articles in 2021 below.

Prone Positioning in Patients With Acute Respiratory Distress Syndrome and Other Respiratory Conditions: Challenges, Complication, and Solutions
Acute respiratory distress syndrome (ARDS) and respiratory failure—low levels of blood oxygen, resulting in shortness of breath, labored and rapid breathing, and perhaps low blood pressure, confusion, and fatigue—are common complications of infections like the flu and COVID-19.

In the most severe cases, patients must be placed on a ventilator to breathe, and may be positioned face-down for 12 or more hours to alleviate pressure on the lungs and promote better oxygenation. However, remaining in a prone position for extended periods of time comes with its own health risks, including skin integrity injuries, such as pressure injuries, blisters, and skin tears; unplanned extubation; cardiac arrest; and dental and ophthalmic issues.

In this study, a researcher analyzed 98 prone position–related events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) from January 1, 2010, through June 30, 2020. Assessing the various risk factors of this common treatment for ARDS, which have evidence-based recommendations to mitigate them, is essential for healthcare teams to prepare, plan, and work together to prevent complications and keep patients safer.

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Wrong-Site Surgery in Pennsylvania During 2015–2019: A Study of Variables Associated With 368 Events From 178 Facilities
Although wrong-site surgery (WSS) is considered a “never event”—a medical error or adverse event which is easily identifiable, is preventable, and has serious consequences for patients—it persists as a problem. In fact, every year, 74 patients experience a WSS—in Pennsylvania alone.

WSS includes surgical errors involving the wrong anatomical side, the wrong site, the wrong procedure, and the wrong patient. Researchers studied 368 such events in the Pennsylvania Patient Safety Reporting System (PA-PSRS), reported by 178 facilities from 2015–2019, and provided a detailed breakdown by facility type, anatomical location, and more. This data highlights the ongoing challenge WSS poses and enables facilities to evaluate their own processes and develop strategies to reduce the likelihood of WSS, so that one day they will truly never happen.

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2020 Pennsylvania Patient Safety Reporting: An Analysis of Serious Events and Incidents from the Nation’s Largest Event Reporting Database
In conjunction with the Patient Safety Authority 2020 Annual Report, we published two articles in Patient Safety analyzing 2020 data from the Pennsylvania Patient Safety Reporting System (PA-PSRS), the nation’s largest event reporting database. In this article, data analysts take a close look at the 278,548 incidents and serious events reported by acute care facilities in 2020. This supplements the data overview in the annual report with a comprehensive review and analysis of events reported in 2020, as well as insights into patient safety in Pennsylvania and how we may continue to improve it together.

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Risk of Medication Errors With Infusion Pumps: A Study of 1,004 Events From 132 Hospitals Across Pennsylvania
Every day in every hospital, infusion pumps deliver vital medications and nutrients to patients. The risk of medication errors with infusion pumps is well established, but to better understand the scenarios and factors associated with them, analysts studied the frequency of medication errors with infusion pumps in Pennsylvania. Among their discoveries: Most wrong rate errors led to medication being infused at a faster rate than intended, and user programming was the most common contributing factor.

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Patient Harm Resulting From Medication Reconciliation Process Failures: A Study of Serious Events Reported by Pennsylvania Hospitals
Managing a patient’s medication is complex and resource intensive, particularly whenever there is a change in care or therapies, requiring clear communication, documentation, and participation between healthcare providers and the patient. The consequences of getting a medication wrong are serious and potentially life-threatening.

This ongoing process of medication reconciliation must take into consideration the current and previous medications, new medications being ordered, changes in the patient’s condition, current therapies, and a whole host of other factors to avoid medication errors like omissions, duplication errors, dosing errors and drug interactions. There are many challenges to overcome, including demands on staff at every stage, but by identifying and understanding the common problems, errors, and drugs associated with medication reconciliation, clinicians can apply appropriate risk reduction strategies to better protect their patients.

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In case you missed them, here are some other great and always timely reads.

Newborn Falls in Pennsylvania: An Analysis of Recent Events and a Review of Prevention Strategies
Despite all the efforts new parents spend babyproofing their homes, one serious risk often goes overlooked: infant falls. However, newborn falls are a very real danger, even in the hospital. Annie and Brad Donnelly learned firsthand just how easily and suddenly a child can fall, particularly when mom and dad are exhausted.

“While Brad was holding Connor in the bed, he became so comfortable that he accidentally fell asleep,” Annie shares. “The railing was up on one side but not the other, and that’s where Connor slipped out of Brad’s hands and received a contusion on the left side of his head. It happened very fast.”

An analysis of data concerning newborn falls in Pennsylvania reveals the surprising prevalence of this problem and its causes, as well as some actionable prevention strategies. It also highlights another need, according to Annie: “I think hospitals need to not only provide education to parents and caregivers, but also show some care and concern for the parents who experience a fall accident.”

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Violence Against Healthcare Workers
As patient safety improves, safety for healthcare workers seems to be getting worse. According to the International Association for Healthcare Security and Safety Foundation, assault rates are at an all-time high since 2012, at a rate of 11.7 per 100 beds, and so is disorderly conduct, at 45.2 per bed. Other reports from around the United States show high rates of injury among healthcare workers, and that a significant number of these victims are working in fear—and there’s good reason to assume these incidents are grossly underreported. Patient Safety Authority Executive Director Regina Hoffman, MBA, RN, examines one of today’s biggest issues and raises the question: How can we reduce danger and violence in the workplace?

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Where There’s Smoke: Validating a Nonproprietary Single-Item Burnout-Impacting-Safety Scale
Burnout is a serious problem for clinicians as well as the patients who rely on them for safe care, and the challenge has only been compounded by the stresses and trauma of the pandemic. Wouldn’t it be helpful if there were a tool that could assess whether your clinical staff is burning out?

A recent study showed that healthcare administrators could use a single survey item to see how their clinicians are doing. The question it asked was, “Are there individuals at your work location who are so burned out that the quality or safety of research, clinical care, or other important work product is impacted?” The respondents’ perception of the impact of burnout on quality safety of healthcare was self-reported using a 5-point system, ranging from 1 (“no burnout or it doesn’t impact safety and quality”) to 5 (“a serious impact on quality and safety”).

This nonproprietary, single-item burnout-impacting safety scale showed a sensitivity of 82% using 4 on the scale as a cutoff (“there is quite a bit of impact of burnout on safety and quality”), indicating this tool may be effective in helping determine what healthcare providers may be at high risk for safety events affecting patients.

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