Digital Commons Network^™

A Heuristic Tool To Enable Root Cause Analysis Of Safety Events, William D. Porter, Kianca Joseph, Demitria Stafford, Kurt Larson, John Mier, Michelle Butler-Jackson, Musaddiq Waheed

HCA Healthcare Journal of Medicine

Background

Hospitals routinely collect wide-ranging data related to quality, efficiency, and clinical practice. As part of these efforts, patient safety event data are collected, compiled, and analyzed to drive process improvement.

Methods

We present a novel adaptation and application of the Department of Defense Human Factors Analysis and Classification System (HFACS) as a heuristic tool to improve the conduct of root cause analysis (RCA) sessions that follow serious patient safety events. To assess individual knowledge improvement after reviewing the heuristic tool, a 1-page summary (including a graphical image of the tool) was developed and provided to a convenience sample of …

The Use Of Infra-Red Spectroscopy To Assess Intact Skin Of Various Skin Tones, Mary Lee A. Potter, Stacie Sosa, Charlott Polm, Sherry Campton, Wisam Salameh, Ronnie Klein, Yaniv Cohen

HCA Healthcare Journal of Medicine

Background

Pressure injuries (PI) continue to be a serious medical complication in the acute care setting. Industry leaders advocate for the use of objective technologies to provide accurate and quantifiable skin assessments for all patients across diverse skin tones. The Infra-Red Spectroscopy Scanner (IRSS) is a novel non-invasive decision support system (DSS) electro-optic technology that uses near infra-red spectroscopy to examine and assess physical and chemical changes prior to visual skin breakdown in real-time.

Methods

A 2-phase prospective open-label pilot device study was launched under protocol IRM-02-1123 (USA version 3.0, November 1, 2023). In both Phase 1 and Phase 2, …

Building A Culture Of Safety Through Faculty Mentorship: The Peer Pairing Framework For Clinical Nurse Educators, Clare A. Chambers

HCA Healthcare Journal of Medicine

Background

Clinical nurse educators often transition from bedside practice to clinical education in high-risk settings without structured support. Limited or absent mentorship during this transition may affect educator confidence, student learning outcomes, patient outcomes, and the ability to sustain a culture of safety. Although mentorship is widely recommended in nursing education, implementation strategies remain limited. The Peer Pairing Framework was developed as a staged mentorship approach to support clinical nurse educators and inform a comprehensive mentorship model.

Methods

The Peer Pairing Framework was informed by a voluntary onboarding survey of 914 clinical faculty, of whom 73.52% expressed interest in having …

Critical Care Catalyst: The Impact Of Trauma Nurse Leads On Mortality, Patient Outcomes, And Throughput, Danielle Brady, Jessica L. Brady, Hannah Dice, Parker Hu

HCA Healthcare Journal of Medicine

Background

Trauma is the leading cause of years of life lost in the United States. Dedicated trauma nurse leaders (TNLs) coordinate resuscitation and streamline care, but data evaluating their clinical impact at level I trauma centers are limited. We evaluated the association between a newly implemented dedicated TNL program and patient outcomes.

Methods

This single-center, preimplementation and postimplementation observational study at an urban level I trauma center compared adult tier 1 and tier 2 trauma activations from the pre-TNL period (January 1, 2017, through April 30, 2020) with the post-TNL period (May 1, 2020, through December 31, 2023; 8 dedicated …

Retrospective Exploratory Pre And Post Evaluation Of Waste Anesthetic Gas Scavenging System And Association With Post Anesthesia Care Unit (Pacu) Nurse Health, Jessica Garibay, Dina A. Krenzischek, Ryan Macdonald, Elizabeth Card

HCA Healthcare Journal of Medicine

Background

The Occupational Safety and Health Administration (OSHA) recognizes the negative health impact of occupational exposure to anesthetic gases in the operating room. As a result, OSHA has implemented regulations, engineering controls, and regular air quality surveillance programs to protect surgical staff. However, immediate postoperative patients exhale waste anesthetic gases (WAGs) into the Post Anesthesia Care Unit (PACU) environment, exposing nurses to occupational health risks, including headaches, fatigue, organ damage, cancer, and reproductive complications. The PACU lacks any regulations or even recognition of this safety issue; in fact, most nurses and leadership are unaware. One potential solution, a scavenging oxygen …

Laboratory Study Of A Waste Anesthetic Gas Mask Scavenging System To Reduce Airborne Pathogen Exposure For Health Care Workers In Post Anesthesia Care Units, Josh Horton, Trevor Lim, Andrew Kanach, John Moenning, James Mcglothlin, Bruce M. Applegate Sr.

HCA Healthcare Journal of Medicine

Introduction

A scavenging oxygen mask system (SOMS) utilizing house vacuum has been demonstrated to significantly reduce exposure of post anesthesia care unit (PACU) health care workers (HCWs) to waste anesthetic gases (WAGs). Therefore, it was proposed that the same system could also be used to protect HCWs in the PACU by reducing Infectious Respiratory Particles (IRPs) spread from patients who may harbor airborne infective pathogens, such as Mycobacterium tuberculosis, certain strains of influenza, and SARS-CoV-2.

Methods

A life-like adult manikin head equipped with a bio-aerosol Collison nebulizer was set up to simulate patients exhausting pathogenic droplets. Further evaluation of …

A Nurse-Driven Escalation In Trauma Team Activation Reduces Mortality Of Injured Patients, Darrell L. Hunt, Yingxian Liu, Jordan S. Rahm, Bailey Segura, Mercedes Huens, Emily Lopez, Esther Krinsky, Joe Spinell, Andrea Palmer

HCA Healthcare Journal of Medicine

Background

There is a dearth of literature examining the clinical outcomes of injured patients who experience physiological deterioration in the emergency department (ED). At our trauma center, injured patients who develop hemodynamic, respiratory, or mental status instability after arrival are retriaged and upgraded to a full trauma team activation (fTA). The purpose of this study was to compare the clinical outcomes of patients with fTA based on prehospital signs and symptoms (initial) versus upgraded fTA patients.

Methods

This was a single-center, retrospective cohort study of injured patients presenting to a tertiary trauma center between June 1, 2022, and June 30, …

Adaptations To Medical Education In A State-Specific Abortion Ban Paradigm, Crystal Duncombe, Anthony Sciuva, Shyamalee A. Ramaraj, Douglas Mcgill, Jilian R. Sansbury, Jennifer Risinger, Nayda Parisio Poldiak, William S. Hart

HCA Healthcare Journal of Medicine

The United States (US) Supreme Court’s overturning of Roe v Wade in 2022 via the decision made in Dobbs v Jackson Women’s Health Organization removed the national protection for doctors to perform abortions and made states able to impose restrictions on this medical procedure. This change immediately affected health care availability in the US, with many states outright banning or effectively banning abortion through gestational limits. Immediate negative effects were reported in populations and locations where maternal health outcomes were already poor, including among Black women and patients living in rural areas. Here we review how the Dobbs decision disrupted …

Making Diagnostic Uncertainty Visible At Intensive Care Unit Transitions: A Narrative Review Of Diagnostic Pause Strategies, Raha West, Ahmed Elhaddad, Behrad Baharlo, Parind Patel

HCA Healthcare Journal of Medicine

Background

Diagnostic error is a significant patient safety issue in critical care. However, it is often difficult to detect during ongoing care. Patients in the Intensive Care Unit (ICU) often have incomplete histories, overlapping symptoms, changing physiology, and concurrent issues. During ICU transitions, patient diagnoses are often reported without clear information on diagnostic confidence, potential alternative diagnoses, pending results, or triggers needing review.

Methods

This clinical narrative review explored diagnostic uncertainty at ICU transitions, specifically those during ICU-to-ward transfers or unplanned escalations to the ICU. A targeted literature search identified studies of adult ICU diagnostic errors, ICU transition safety, ICU-PAUSE …

Beyond Bed Numbers: A Proposed Quality Improvement Framework For Reviewing Icu Acuity, Workload, And Medical Staffing, Raha West, Ahmed Elhaddad, Behrad Baharlo, Parind Patel

HCA Healthcare Journal of Medicine

Background

Intensive care unit (ICU) medical staffing is often planned using bed numbers or fixed ratios. These counts do not describe the work required when patients deteriorate, urgent tasks overlap, or clinicians have duties outside the unit. A structured review could help teams discuss whether available cover can meet these demands.

Methods

We undertook a targeted narrative synthesis of adult ICU staffing guidance, acuity and workload measures, physician workload studies, and capacity-strain research available through 8 September 2026. We examined study settings, findings, and limitations to inform the framework domains. The authors proposed the review prompts and response options. No …

Brief, Handoff, Backbrief, Forecast, Review: A Communication Cycle For Safer Trauma And Surgical Intensive Care Unit Transitions, Constantine Stephens, Saptarshi Biswas

HCA Healthcare Journal of Medicine

Safety in trauma and surgical critical care is inseparable from the reliability of communication at transitions of care. Handoffs are recurrent, high-risk moments in which teams transfer not only information but responsibility, prioritization, uncertainty, and contingency planning; failures at these points propagate into omissions, delayed escalation, and preventable harm to patients and strain on the workforce. Structured handoff tools improve completeness and clarity but inconsistently change hard clinical endpoints, and tools alone do not create the culture of safety on which high-reliability organizations (HROs) depend. This narrative review synthesizes civilian handoff research, human-factors and HRO theory, situation-awareness, psychological safety, trauma …

Bathrooms As A Patient Safety Blind Spot In Emergency Departments: A Narrative Review And Nursing Practice Framework, Carmelo Villani

HCA Healthcare Journal of Medicine

Background

Emergency department (ED) bathrooms preserve privacy and dignity but interrupt direct observation. Risks described across clinical publications and professional guidance include falls, unrecognized deterioration, overdose, hazardous ingestion, infection, inaccessible environments, and unmet elimination needs. This review integrated those risks and translated them into a nursing practice framework.

Methods

For the structured narrative review, PubMed/MEDLINE, CINAHL Plus, and Scopus were searched on July 30, 2026, without date, language, age, or publication-type filters. Backward and forward citation chasing and a targeted search for professional documents supplemented database searching. Publications were categorized by ED relevance and synthesized thematically. Professional guidance was analyzed …

From Restraint To Calm: A Narrative Review Of Nonpharmacologic Alternatives To Physical Restraints In Adult Acute Care And Introduction Of The Calm Bedside Restraint Alternatives Framework, Elizabeth Card, Brandi Puet

HCA Healthcare Journal of Medicine

Background

Nurses and health care workers are dedicated to creating a therapeutic environment for healing. Sometimes, physical restraints may be used to ensure safety in patients exhibiting violence, confusion, or agitation, or in patients with life-saving medical devices. While the regulatory requirements for use of physical restraints are well developed, this is not the case with alternatives to using restraints, and many nurses may lack clarity on the best practice for identification and application of alternatives to physical restraint use.

Methods

Two trained reviewers searched PubMed, Google Scholar, and professional health care organizations’ websites guided by a search strategy and …

A Digital Safety Detection And Control System For Proactive Risk Management, Karla Miller, Jennifer Lee Mcalister, Keri Melson, Gita Nadimpalli, Becca Moore, Brett Powell, Kenneth E. Sands, Mary Catherine Harris, Cali Cerami, Shanna Arnold Egloff, Yauheni Solad, Randy Fagin

HCA Healthcare Journal of Medicine

Patient safety remains a defining dimension of health care quality, yet systems rely on retrospective assessment after harm has occurred, limiting visibility into upstream risks, including process failures and near misses. This challenge underscores the need for an approach that unifies fragmented safety activities to support proactive safety risk management. We describe a phased pilot implementation and evaluation framework of a Digital Safety Detection and Control System (DSDC) within a large integrated health care system to operationalize enterprise-wide patient safety. The DSDC integrates governance, human oversight, and digital capabilities across 4 operational phases: detection, triage, investigation, and learning. These capabilities …

Pharmacovigilance As An Act Of Awareness And Mindfulness, Mahima Silas, Hale Z. Toklu

HCA Healthcare Journal of Medicine

The term “pharmacovigilance” defines the activities related to the collection, detection, assessment, monitoring, and prevention of adverse reactions due to pharmaceuticals. While it is often framed as a technical and regulatory discipline, it can also be understood through a more reflective lens as a form of mindfulness practice. At its core, pharmacovigilance requires a way of thinking that closely mirrors mindfulness, including sustained attention, openness to uncertainty, and deep awareness of human experience. Viewing pharmacovigilance in this way reframes it not just as a safety mechanism, but as a thoughtful, patient-centered approach to medicine.

Unheard Voices: Reducing Psychological Barriers To Publication In Nursing Research, Caryn R. Alper

HCA Healthcare Journal of Medicine

Despite their interest in clinical inquiry, many nurses face psychological barriers, including imposter syndrome (IS), that prevent them from engaging in research and disseminating their findings. This editorial explores how psychologically safe work environments can help counter these barriers through supportive leadership, respect, and mentorship to strengthen skills and confidence and reduce vulnerability in scholarly work. Normalizing self-doubt and creating environments where nurses feel safe asking questions and testing ideas can help more nurses recognize the value of their expertise and contribute their voice to the base of evidence.

Psychological Safety Is Everyone’S Work: A Call To Practice, Education, And Leadership In Nursing, Gina Rivera

HCA Healthcare Journal of Medicine

Psychological safety is essential to nursing practice, education, and leadership because it enables individuals to speak up, ask questions, report concerns, and learn from mistakes without fear of humiliation or blame. In health care settings, psychological safety supports patient safety by encouraging error reporting, timely escalation, and interprofessional collaboration. For nurses, it strengthens teamwork, accountability, well-being, and retention in complex, high-pressure environments. In nursing education, psychological safety allows students to admit uncertainty, engage in feedback, and develop clinical judgment across simulation, clinical, didactic, and online learning spaces. This article argues that psychological safety is often discussed separately across practice, academia, …

No Place For Workplace Violence, Ryan Sledge

HCA Healthcare Journal of Medicine

Workplace violence in health care is often discussed as an employee safety issue, but that framing misses a larger operational reality. Violent incidents affect the individuals involved, but they also disrupt care delivery, strain teams, reduce patient safety, contribute to health care worker burnout, and expose organizational conditions that leaders cannot afford to ignore. Incident reports rarely tell the full story. In many settings, aggressive behavior becomes normalized to the point that staff stop reporting much of what they experience. This creates a false sense of awareness and visibility. This editorial argues that health care leaders should approach workplace violence …

Safer Together: A Special Nursing Issue Focusing On Safety In Health Care, Tracy A. Ortelli, Lori M. Brodie

HCA Healthcare Journal of Medicine

Safety is a shared responsibility dependent upon the collective efforts of health care professionals, educators, leaders, organizations, and systems. This special nurse-led issue of the HCA Healthcare Journal of Medicine highlights scholarly works addressing education, clinical practice, and health care workforces. We are informed about safety through research, clinical reviews, case-based learning, and education. This issue was created to inspire the entire health care workforce to pursue continuous improvement to make health care safer together.

Development And Implementation Of A Scholarly Curriculum For Internal Medicine Residents And Subspecialty Fellows, Yuri Matusov, Hawas Kaderi, Liza Raffi, Louie Cao, Jacqueline Lee, Mariko Ishimori, Odelia Cooper

Graduate Medical Education Research Journal

Background. To create and assess the efficacy of a standardized curriculum for trainees in the core competency of critical appraisal of medical literature.

Methods. We implemented a 10-hour scholarly lecture curriculum, in 1-hour blocks, over 1 academic year for postgraduate trainees in internal medicine (IM) and IM subspecialties at a single major academic medical center. The aims of the curriculum were to increase trainee comfort with clinical research methodology, to place this methodology in the context of historical and current ethical challenges, to provide trainees with guidance on how to conduct clinical research at the institutional level, and to provide …

Asteroid Hyalosis Mimicking Vitreous Hemorrhage On Point-Of-Care Ultrasound Following Blunt Ocular Trauma: A Case Report, Obiaara Ukah, Jared Marx

Graduate Medical Education Research Journal

Background. Ocular complaints account for approximately 1.5% of emergency department (ED) visits, and point-of-care ultrasound (POCUS) is a valuable tool for evaluating posterior chamber pathology, including vitreous hemorrhage (VH), retinal detachment, and vitreous detachment. However, benign conditions may mimic these pathologies and create diagnostic uncertainty. We describe a case of asteroid hyalosis (AH), a benign vitreous condition that was initially mistaken for vitreous hemorrhage on ocular POCUS following blunt ocular trauma. This case highlights an uncommon sonographic mimic of VH and contributes to the emergency medicine literature by emphasizing ultrasound features that may help distinguish AH from true posterior chamber …

Kaposi Sarcoma And Hhv-8-Associated Multicentric Castleman Disease: A Case Report, Kari Shad, Avry Logeman, Trevor C. Van Schooneveld, Emily Dyer

Graduate Medical Education Research Journal

Background. Multicentric Castleman disease (MCD) is a rare lymphoproliferative disorder characterized by generalized lymphadenopathy, systemic inflammatory symptoms, and distinctive histopathologic findings. HHV-8-associated MCD is typically observed in patients with human immunodeficiency virus (HIV) infection or other states of profound immunosuppression. In contrast, HHV-8-associated disease in immunocompetent individuals is uncommon and associated with higher mortality rates.

Case. This is a case of a patient who presented with progressive fatigue, weakness, anorexia, and a chronic cough for four months following a trip to Mexico. Initial workup revealed anemia and thrombocytopenia, negative HIV status, and prominent bilateral axillary and mediastinal lymphadenopathy, which was …

Emergent Endovascular Therapy For Malignant Superior Vena Cava Syndrome Complicated By Extensive Central Venous Thrombosis: A Case Report, Austin Johnson, Andrew Mezher, Ehab Saad Aldin, Lei Yu

Graduate Medical Education Research Journal

Background. Superior vena cava (SVC) syndrome is a potentially life-threatening condition caused by obstruction of venous return through the SVC, most commonly due to malignancy. Although endovascular therapy (ET) has emerged as an effective treatment for rapid symptom relief, malignant SVC syndrome complicated by extensive central venous thrombosis and respiratory failure remains a high-acuity presentation requiring urgent intervention. This case highlights the role of emergent ET as a life-saving bridge to definitive oncologic treatment in critically ill patients.

Case. A 58-year-old male with squamous cell carcinoma of the lung presented with acute respiratory failure, facial and upper extremity swelling, and …

Strategies For Building Relationships In The Secondary English Language Arts Classroom, Emily S. Nipper

Journal of Educational Research and Practice

Building positive relationships with students is at the forefront of good teaching practices. While secondary teachers in the English language arts (ELA) classroom are increasingly overwhelmed with demands to improve literacy and test scores, positive relationships can help students feel supported in the classroom and more engaged in learning, which can help prevent them from demonstrating negative behaviors. Drawing on research on developing and valuing positive relationships in secondary classrooms, this article translates research into practice by examining how teachers can use discipline-specific strategies to foster supportive and positive relationships with students.

Ruth Mae Mott Bc 1938 Collection Finding Aid

Finding Aids

No abstract provided.

Battle Of The Bots: Comparison Of Artificial Intelligence Chatbots In A Literature Review Of Randomized Controlled Trials In Urology, Linda M. Huynh, Madeline Helm, Nick Staab, Anthony Fadel, Jordan Walsh, John Glassman, Christopher M. Deibert

Graduate Medical Education Research Journal

Background. Use of language-learning model-based artificial intelligence (AI) chatbots in literature reviews has not been explored. The present study seeks to evaluate and compare the quality of reference lists and scientific discussion provided by ChatGPT (Chat Generative Pre-Trained Transformer) (4o vs. 4) and Google Gemini.

Methods. ChatGPT (4o-mini, paid vs. 4o, free) and Google Gemini were given prompts to identify, discuss results of, and provide related references to nine specific randomized controlled trials in urologic practice. Reference lists and associated discussion were graded using modified DISCERN criteria. Hallucination rates for unverifiable references were calculated; GPT-2 Output Detector and Sapling AI …

Learning By Peer Teaching Basic Life Support: A Prospective Randomized Controlled Study In Medical Students, Tushar Kumar, Dewesh Kumar, Vandana Sharma, Shio Priye

Graduate Medical Education Research Journal

Background. Cardiopulmonary Resuscitation (CPR) is a vital emergency procedure performed in case of cardiac arrest or respiratory insufficiency. However, this basic yet important skill is lacking in many undergraduate students. We aim to evaluate the impact of a teaching-learning method, “learning by teaching,” among medical undergraduate students for cardiopulmonary resuscitation.

Methods. A total of 49 undergraduate medical students in the 3rd-year Bachelor of Medicine and Bachelor of Surgery (MBBS) were divided into 2 groups in a 1:1 ratio, namely, the teaching group (Group T) and the non-teaching group (Group NT). The intervention was done after the hands-on workshop on Life …

Iatrogenic Popliteus Tendon Injury During Total Knee Arthroplasty, Saswat Samant, Bibhudutta Sahoo, Saurav Narayan Nanda, Suman Mishra, Satya Ranjan Patra, Himanshu Mishra

Graduate Medical Education Research Journal

Background. The popliteus tendon (PT) plays a role in knee unlocking and posterolateral stability, yet the clinical impact of its iatrogenic injury during total knee replacement (TKR) remains poorly defined. This study aimed to evaluate the outcomes of patients with documented intraoperative PT injury during posterior-stabilised TKR.

Methods. A retrospective review was conducted on 111 varus knees undergoing posterior-stabilised TKR. Among these, seven cases (6.3%) of intraoperative PT injury were identified. The cohort had a mean age of 71 years and an average preoperative varus deformity of 14°. PT repair was performed in two of the seven injured cases.

Results. …

Ritualidad, Memoria Y Cosmovisión: Ámbitos De La Tradición Sonora Entre Los Mayas Peninsulares, Juan Carrillo González

Journal of Maya Heritage

El presente trabajo se centra en esclarecer los contenidos estructurales de la tradición sonora entre los mayas peninsulares a través del análisis del pensamiento mítico y las prácticas ceremoniales. Estos elementos, al enmarcarse en un contexto de larga duración, abren asimismo la posibilidad de esclarecer la correlación entre pasado y presente de la confección instrumental especializada realizada por los artesanos indígenas peninsulares, así como la preservación de distintas convenciones de la musicalidad que han permanecido articuladas a la cosmovisión. La investigación conjuga distintos hallazgos que se desprenden de la compilación de fuentes documentales primarias, relatos provenientes de viajeros decimonónicos y …

The Effects Of Pediatric Asthma On Daily Activities And Family Life In Cache Valley, Utah: Exploring Parental Perceptions Of Air Quality, Saeed Ahmad, Mehmet Soyer, Landon Lloyd, Mayu Mecham

Transforming Communities

Asthma is one of the main chronic health conditions affecting children living in Cache Valley, Utah particularly due to poor air quality during the winter season. It is very important to understand how families manage asthma both within and outside the household. Therefore, this research brief highlights how parents are managing pediatric asthma, and how asthma influences daily activities and family life. It is based on a qualitative study that extracted the data from 20 in-depth interviews with parents of asthmatic children. Participants were recruited through purposive snowball sampling. Data were collected through an interview guide that included some basic …