Patient Safety Commons^™

Trust As Public Health Infrastructure: Advancing Health Care Safety Through Risk Communication And Community Engagement, Karanvir Bhinder, Sahibpreet Bhinder

HCA Healthcare Journal of Medicine

Background

Preparedness frameworks traditionally emphasize surveillance, laboratory capacity, clinical care and logistics. However, recent public health emergencies have demonstrated that even technically sound interventions may fail when trust is weak, communication is fragmented or misinformation undermines public confidence. Risk communication and community engagement (RCCE) is therefore increasingly recognized as an important component of effective outbreak response.

Perspective

Evidence from COVID-19, Ebola and other public health emergencies demonstrates that trust, communication and community engagement influence adherence to public health guidance, vaccine acceptance, healthcare utilization and the implementation of evidence-based interventions. Despite this, RCCE is frequently operationalized as a support function rather …

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.

State-Level Implementation Of Health And Safety Policies In Mississippi Secondary Schools, Heather L. Shirley, Valerie J. Moody

Internet Journal of Allied Health Sciences and Practice

Background: State-level investigations of health and safety policy implementation in secondary school athletics highlight ongoing challenges in ensuring student-athlete safety that aligns with evidence-based best practices. Purpose: The purpose of this study was to examine current state-level implementation of health and safety policies in Mississippi secondary schools from the perspective of athletics/activities directors, athletic trainers, and other school administrators. Methods: In May 2025, a 26-item web-based questionnaire was distributed to 226 athletic directors and 114 athletic trainers across Mississippi secondary schools. The survey assessed participant demographics, access to healthcare resources, emergency action planning (EAP), required coaches’ health and safety training, …

“Now Serving… Not Quite Yet”: Improving Waiting Room Experience Through Consistent Communication In The Emergency Department, Juan Carlos Serrato

Master's Projects and Capstones

Context: The quality improvement project was implemented in the front-end microsystem of a 36-bed emergency department (ED) in a non-profit, Magnet-designated California hospital. Problem: Communication with non-roomed patients at Hospital X was inconsistent, contributing to dissatisfaction. In June 2026, Press Ganey reported that 61.4% of patients felt they were informed about delays. Baseline observation identified gaps in staff explanations of estimated wait times, next steps in care, and opportunities to ask questions. Intervention: A 30-day pilot provided staff education on the AIDET communication framework through formal in-service education and daily huddles. Patient-facing materials explained the ED process …

Diagnostic Trends And Service Enhancements In Deaf Mental Health: A Longitudinal Analysis, Kent Schafer, Steve Hamerdinger, Frank Wu, Rie Sakai Bizmark, Charlene Crump

JADARA

A longitudinal study investigated mental health diagnostic trends and patterns among Deaf and Hearing individuals using a comprehensive dataset from Alabama Department of Mental Health spanning 2004-2024 (Deaf=4,547; Hearing=2,056,188). Chi-square analysis revealed significant proportional differences in diagnoses between the groups. Deaf individuals showed significantly higher proportions of psychotic (12.93% vs. 8.33% Hearing), mood (20.76% vs. 18.84% Hearing), and personality (0.58% vs. 0.43% Hearing) disorders. These findings suggest that increased access to specialized and competent mental health services for individuals who are Deaf, particularly following the increase of staffing patterns for the Office of Deaf Services in 2015,contributed to more accurate …

Prephiral Bacterial Infectious Agent Triggers Neuroinflammatory Responses And Neurobehavioral Impairment In Wild-Type Mice, Hadeer Atalah

Theses and Dissertations

Neurodegenerative diseases, including Alzheimer's and Parkinson's, present an increasing global challenge, with chronic neuroinflammation identified as a principal factor alongside genetic, environmental, and infectious influences (Boyd et al., 2022).  Epidemiological data associate bacterial infections with a 40% heightened risk of Parkinson's disease; however, the mechanisms—especially the direct connection between peripheral sepsis and the silent onset of central nervous system pathology absent acute meningitis—are inadequately investigated (Smeyne et al., 2021), particularly concerning common pathogens like Klebsiella pneumoniae in high-burden areas such as Egyptian ICUs, where it constitutes 30% of cases (Alkompoz et al., 2023). This study filled the gap by creating …

A Pilot Study Evaluating Child Resistant Closures In Pharmaceuticals In The Developing Nation Of Ghana: Informing Global Paediatric Safety And Usability Standards, Samuel Ofosu, Kojo Agyapong Afrifah, Laura Bix

Journal of Applied Packaging Research

Despite their proven effectiveness in preventing unintentional paediatric medication poisoning in high-income countries, the performance and usability of Child Resistant Closures (CRCs) remain underexplored in low and middle-income countries (LMICs).

To provide pilot data regarding the potential efficacy of using CRCs in LMICs, we conducted a study of the approach in a low-resourced region (Ghana, West Africa) by adapting testing protocols utilized in the United States (16 CFR Part 1700.20). The study utilized a convenience sample of children (n=50; 42-51 months) and adults (n=50; 50-70 years) to develop preliminary data related to the efficacy of a single design of CRC …

Ask Me 3® In Action: Advancing Health Literacy In Pediatric Acute Care, Yaseming Medina

2026

This evidence-based practice project evaluated the implementation of the Ask Me 3® health literacy tool in a pediatric perioperative setting to improve caregiver understanding of medical information and communication with healthcare providers. Findings suggest that Ask Me 3® supports health literacy and caregiver engagement, while patient experience measures related to nurse communication, listening, and caregiver comfort improved following implementation.

Exploring The Impact Of Adverse Childhood Experiences On Preventive Healthcare Utilization In Rural Georgia, Ryan R. Traylor

College of Graduate Studies: Theses & Dissertations

This study examines the relationship between Adverse Childhood Experiences (ACEs) and preventive healthcare use among adults in Georgia, specifically within rural populations facing structural barriers. Using 2023 Georgia Behavioral Risk Factor Surveillance System (BRFSS) data, the research analyzes associations between ACE exposure, rural residence, and preventive care outcomes, including physical exams and flu vaccinations. Guided by an intersectionally adapted version of Andersen’s Behavioral Model of Health Services Use, the study evaluates how predisposing factors, enabling resources, and perceived barriers relate to healthcare engagement. Logistic regression analyses assess the correlation of ACE exposure, cost barriers, provider access, and sociodemographics with preventive …

A Cross-Sectional Study On Patient Safety Attitudes And Their Determinants Among Medical Staff In Malaysian Public Specialist Hospitals, Sharifah Balqis Sayed Abdul Hamid, Aniza Ismail, Saperi Sulong

Makara Journal of Health Research

Introduction: This study aimed to assess the baseline level and mean scores of patient safety attitude domains among doctors and nurses in Malaysian public hospitals and to identify determinants associated with these attitudes across six domains: teamwork, safety climate, working conditions, job satisfaction, stress recognition, and perception of management.

Methods: A cross-sectional study was conducted using the Safety Attitudes Questionnaire (SAQ) among 142 doctors and 231 nurses from three public tertiary hospitals. Participants were selected through proportionate stratified random sampling. Data were analyzed using descriptive, bivariate, and multivariate methods.

Results: The study achieved an 81% response rate. …

A Quality Improvement Initiative To Streamline Flu Vaccine Documentation And Increase Staff Engagement, Carla E. Giron

Master's Projects and Capstones

Objective: This quality improvement project was implemented in an urban community health clinic primarily serving low-income and Latinx patients. Factors such as demographics, socioeconomic status, health, and transportation contribute to low U.S. influenza vaccination rates (Chen et al., 2020), while EHR training can improve provider satisfaction and efficiency (DiAngi et al., 2019). This microsystem faced inconsistent workflow processes, limited EHR training, and documentation errors that contributed to low staff satisfaction rates and influenza vaccination rates. An average of 11.4% of patients received a flu vaccine in October 2023 and 2024. Medical assistants (MAs) completed a pre-intervention survey indicating that 35% …

Increasing Pediatric Hpv Vaccination Rates, Brooke A. Nicholas

Dissertations

Increasing Pediatric HPV Vaccination Rates

Abstract

Problem: The human papillomavirus (HPV) is a sexually transmitted infection that affects more than 80% of the population within the United States (Eisenhauer et al., 2020). HPV can develop into cervical, anogenital, and oropharyngeal cancers (Eisenhauer et al., 2020). About 4,000 individuals die from cervical cancer alone each year (O’Leary, 2022). The HPV vaccine, though recommended by the ACIP and AAP, is below national vaccination rates in comparison to other vaccines (O’Leary, 2022).

Methods: This quality improvement project is a non-randomized controlled trial that observed HPV vaccine dose completion rates for patients aged 9-14 …

America's Physician Shortage: Look To Pas, Not Abroad, Raquelle Akavan, Laura Juarez

Lynchburg Journal of Medical Science

The United States has long addressed physician shortages by recruiting international medical graduates (IMGs), often from low- and- middle income countries. This "brain drain" deprives already fragile health systems and adds to worldwide health disparities. New state legislation has eased licensing standards for IMGs and generated variable training pathways creating patient safety risk in underserved groups. At the same time, the U.S. has a sustainable, highly trained, and proven ready workforce: physician associates (PA). Created in the 1960s to address physician shortages, PAs undergo intensive graduate-degree education, uniform clinical education, and national certification on par with physicians. Nonetheless, obsolete laws …

Blueprint For A Youth Violence Intervention Program In East Baton Rouge Parish: Adapting Hospital-Based Strategies, Kristina G. Little, Elizabeth Winchester, Judith L F Rhodes

Reports

Youth violence in East Baton Rouge Parish remains a persistent public safety and public health challenge. This report proposes an adapted, evidence-informed model for East Baton Rouge Parish that retains the core components of traditional HVIPs while leveraging existing legal, hospital, and social service resources. The model is grounded in a public health framework and emphasizes trauma-informed, bedside intervention at the “teachable moment” when youth are most receptive to change, and long-term wraparound case management. The report concludes with recommendations for implementing this adapted approach, including identifying a health system champion, building referral protocols, embedding training, and developing a long-term …

Understanding Vaccine Hesitancy And Barriers To Access In Hispanic Individuals Of Metro Detroit​, Rafael Ramos, John Gallegher, Nevil Khurana, Ingrid Rocha, Rene Andino-Galva, Izabel Thomas, Deni Peterson, Alexander Eskandarian, Eliezer Arody Gomez, Md

Medical Student Research Symposium

Background:

Detroit’s Hispanic community is still disproportionally uninsured at about 2x the rate of non-Hispanic white and 3x the rate of non-Hispanic Black residents. In the post-COVID era, vaccine hesitancy and barriers to access have been well-documented. Studies suggest that minority populations, including the Hispanic population, may experience unique social determinants of health which affect their vaccination rates and outcomes. Additionally, research shows that knowledge of vaccines may correlate with levels of trust.

Methods:

We sought to describe the knowledge, barriers to access, and levels of trust regarding the influenza (flu) vaccine in Hispanic individuals of Metro Detroit. We used …

Enhancing Healthcare-Associated Infection Prevention: The Role Of Hand Hygiene, Ppe, Isolation, And Vaccination Education, Kaitlyn N. Rollo

Aurora

Healthcare-associated infections (HAIs) represent a significant threat to patient safety in hospital environments. These infections are often linked to lapses in infection prevention protocols, including inadequate hand hygiene, improper use of personal protective equipment (PPE), and insufficient isolation procedures. This project aimed to evaluate compliance with infection control policies and identify areas for improvement at Lima Memorial Hospital. By focusing on auditing, education, and data analysis, the goal was to reduce HAI rates and strengthen overall infection prevention practices.

Methods included a comprehensive review of existing hospital infection prevention policies, followed by hand hygiene and PPE audits across the hospital’s …

Psychological Treatment Behind The Walls:Insights From The Inside, Rogelio Serrano

Psychology Division Scholarship

Repeated eras of mass incarceration, criminalization of marginalized communities, and substance use policies have created a revolving door of justice involved populations. The ever-increasing prison population has repeatedly become the largest contingency of mental health clientele for an overburdened mental health system. Those who work with formerly incarcerated individuals in the community often don’t know the unique set of challenges faced by practitioners within the system. Increased understanding and coordination of care can offer opportunities for sustained recovery and reduced levels of recidivism. In this presentation participants will learn about the unique insights on mental health treatment that can be …

Exploring The Causes Of Plwha Non-Adherence With Antiretroviral Therapy: Implications For Practice In The Post-Covid-19 Era, A Phenomenological Study, Adriani Suwito, Evi Hasnita, Nurhayati -. Nurhayati, Oktavianis -. Oktavianis

The Qualitative Report

One of the goals of HIV/AIDS health services is to combat patients’ non-adherence with medication. This is the key to providing effective care for these patients. If a patient is rebellious or undisciplined in following his treatment regimen, the consequences can include decreased production, increased morbidity, and even death. However, in the post-COVID-19 period, where health protocol adherence remains strong, there are concerns regarding the potential spread of HIV/AIDS. The purpose of this qualitative phenomenon study is to investigate the factors that contribute to non-adherence to medicine in HIV/AIDS patients during the post-COVID-19 condition to remove barriers to patient treatment. …

A Comprehensive Study On Clinical Management Of Hypertension Among The Patients From Selected Suburban Region Of Tirupati, Jyothi Basini, Prasanna Rajy Y, Jagadeesh M, Anusha K, Asiya S, Chandrakala G, Nivetha D, Navyasree K, Amarnath Reddy B

International Journal of Health and Allied Sciences

Background: Hypertension (HTN) is the major public health concern and non communicable disease affects 29% of global population by 2025.

Aim: This is study was aimed to explore the awareness and knowledge of hypertension and clinical symptoms among adult hypertensive patients in and around suburban/rural region of Tirupati Municipality.

Method: The assessment study was conducted with aid of informed consent, patient demographic and questionnaire forms. Both male and female participants about 250 at the age above 18 years were included. The study was performed in off-line and on-line mode.

Results: Out of 250 study population 106 …

Neurosurgical Praxis Guidelines During The Covid-19 Outbreak. Consensus-Based On Currently Available Literature., José Antonio Soriano Sánchez, Bárbara Nettel Rueda, José Alberto Israel Romero Rangel, Armando Alpizar Aguirre, Miguel Ángel Andrade-Ramos, Ulises García Dr., Diego Mendez Rosito, Jorge A. Santos, Sara Patricia Pérez Reyes, Julian Eduardo Soto Abraham, Jose E. Valerio Pascua, Marco Antonio Barajas Romero, Eduardo Díaz Juárez, Alma Griselda Ramírez Reyes, Maria Elena Gonzalez, Claudia Katiutska González Valdez, Félix Domínguez Cortinas, Noé Santiago Ramírez, Tenoch Herrada Pineda, Manuel Eduardo Soto García, Edgar Nathal Vera, Gustavo Melo Guzmán

Archives of Neurosurgery

INTRODUCTION: The World Health Organization recommended several strategies to contain the COVID-19 pandemic, including optimization of care for all patients, especially the seriously ill. Given the strain, the pandemic has posed on healthcare systems around the world, many neurosurgical associations have provided triage recommendations for patients to save resources for the pandemic. We aimed to provide practical recommendations based on specific illnesses requiring surgical procedures commonly performed by neurosurgeons on a life-threatening basis of patient illness. We consider this guideline will help neurosurgeons for the appropriate triage of patients on a daily-situation basis during this pandemic.

METHODS: The Mexican Society …

Resilience And Reality: Exploring The Lived Experiences Of People Living With Hiv In Texas During The Covid-19 Pandemic – A Qualitative Study., Ahmed F. Alanazi

Social Work Dissertations - Archive

This study investigated the lived experiences of individuals living with HIV (PLWH) in the Dallas-Fort Worth (DFW) area of Texas during the COVID-19 pandemic, using an Interpretative Phenomenological Analysis (IPA) framework. The research examined the intersection of health, social dynamics, and psychological resilience among PLWH, who faced compounded vulnerabilities due to systemic inequities and the dual public health crises of HIV and COVID-19. Through semi-structured interviews with ten participants from diverse backgrounds, the study captured the profound impacts of disrupted healthcare systems, heightened stigma, and social isolation on this marginalized population. The findings reveal that the pandemic exacerbated existing inequities …

Prepared To Protect: Improving Cardiac Emergency Response Through Education And Action Planning In Youth Club Sports, Melissa Garcia

Nursing | Senior Theses

Sudden cardiac arrest (SCA) is the leading cause of death in youth sports, illuminating the essential demand for adequate emergency response, including cardiopulmonary resuscitation (CPR), automated external defibrillator (AED) usage, and comprehensive emergency action plans (EAPs). Research shows that despite the importance of prompt intervention, the majority of youth club sports programs outside of the school setting lack the training and resources needed to respond effectively to SCA incidents. This study will evaluate the effectiveness of an educational seminar that includes CPR/AED training and EAP simulation exercises in improving participants’ knowledge, skills, and confidence in managing cardiac emergencies. A quasi-experimental …

Investigating The Impact Of Phthalate Exposures From Personal Care Products On Uterine Fibroid Incidence And Prevalence In Us-Born Black Women, Ella Brissett

CMC Senior Theses

Uterine fibroids are benign tumors composed of smooth muscle cells and connective tissue that develop within or on the walls of the uterus. Despite being non-cancerous, they can severely affect quality of life by causing heavy bleeding, chronic pain, and reproductive complications. Fibroids are typically found in women of reproductive age, but they disproportionately affect Black women, who experience higher incidence and severity. The underlying causes of this disparity is poorly understood; however, an emerging body of research is highlighting the role of phthalates, endocrine-disrupting chemicals found in many personal care products, in exacerbating fibroid development. Through a critical analysis …

The Impact Of State-Mandated Certification Of Surgical Technologists On Surgical Site Infection Rates: Evaluating Policy, Practice, And Patient Outcomes, Katherine E. Geiger

Graduate Student Theses, Dissertations, & Professional Papers

Abstract

Chairperson: Matthew Schertz, Ph.D.

Committee Member: Morgen J Alwell, Ph.D.

Committee Member: Jill Davis, M.Ed.

As a surgical technology instructor, I have witnessed firsthand the impact that certified surgical technologists (CSTs) have on patient safety, particularly in the prevention of surgical site infections (SSIs). This professional paper investigates the relationship between state-mandated certification of surgical technologists and SSI rates, with a focus on how standardized education and credentialing influence clinical outcomes. SSIs remain a significant concern in surgical environments, contributing to increased morbidity, longer hospital stays, and greater healthcare costs. The research presented here examines certification requirements across various …

The Impact Of Immigrants On The Number And Type Of Births, Neset Gumusburun, Ergun Mendes

Makara Journal of Health Research

Background: Although cesarean section is a life-saving procedure in certain situations, it may result in complications for maternal and infant health when conducted, especially for nonmedical purposes. The civil war in Syria has significantly modified the demographic and ethnic structure of Turkey, which has affected the number and type of births occurring here. In this study, we aimed to determine the effect of the increasing Syrian refugee patient population on primary cesarean section rates in Kilis/Turkey.

Methods: In this retrospective cohort study, pregnant women who gave birth at the State Hospital in the Kilis province in Turkiye between …

Development And Evaluation Of An Implementation Strategy To Increase Hpv Vaccination Among Underserved Youth Across Texas: A Protocol Paper, Paula M Cuccaro, Jihye Choi, Lara S Savas, Efrat K Gabay, Mayra Aguilar Mcbride, Amy Montelongo Eldridge, Timothy J Walker

Faculty, Staff and Student Publications

BACKGROUND: All for Them is a theory-based and evidence-informed multilevel, multicomponent program delivered through schools to increase HPV vaccination among medically underserved youth across Texas. Given the potential logistical challenges of program implementation, understanding how to best support the implementation and sustainment of the program is critical. The overall goals of this study are twofold: 1) develop a multifaceted implementation strategy, Implementing All for Them (IM-AFT); and 2) evaluate the impact of IM-AFT on implementation outcomes for schools and healthcare providers to successfully implement All for Them in their respective settings.

METHODS: This study is underpinned by a comprehensive and …

Fda Approves Neffy®- First Nasal Spray For Anaphylaxis, Abigail Carter, Penlope Mazivanhanga, Haylee Whyde, Rileigh Rahrig, Ashley Jacob, Anna Spalvieri, Joshua Honaker, Samantha Mccord, Andrew Roecker

Pharmacy and Wellness Review

Between 1.6 and 5.1% of the United States population have experienced anaphylaxis, a severe allergic reaction.1 Anaphylaxis occurs when someone is exposed to an allergen, most commonly foods, medications, and insect venom. Epinephrine is the first-line agent for anaphylaxis treatment, and it is critical to administer this medication immediately after the onset of anaphylactic symptoms to prevent worsening that could lead to death. Epinephrine, more commonly known as EpiPen® or Auvi-Q®, has historically only been available as an intramuscular (IM) injection. Many people are afraid, anxious, or uneducated on how to properly give someone an IM injection, causing anaphylaxis treatment …

Prepared To Protect: Improving Cardiac Emergency Response In Youth Club Sports, Melissa Garcia

Nursing | Student Research Posters

Sudden cardiac arrest (SCA) is a medical emergency where the heart unexpectedly stops beating due to an electrical malfunction. A person experiencing a cardiac arrest collapses, loses consciousness, and ceases breathing (American Heart Association, 2022).

Exercise offers numerous benefits to the cardiovascular system and a person’s overall health. However, there are incidents of sports-related cardiac arrest in apparently healthy athletes, including children and young adults. Athletes may be exposed to dehydration, adrenic surges, electrolyte imbalances, acid/base disturbances, and trauma which increases their risk of experiencing a cardiac event (Wasfy et al., 2016).

Sudden cardiac arrest is the leading cause of …

How Should We Measure Effectiveness Of Medical-Legal Partnerships?, Prashasti Bhatnagar, Deborah F. Perry, Margaret E. Greer

HJA Scholarship

Medical-legal partnerships (MLPs) try to mitigate health inequity by uniting legal and health professionals to respond to legal determinants of patients’ health. While there is a long tradition of “patients-to-policy” work in MLPs, the current empirical evidence base has evaluated MLP effectiveness by assessing benefits to individual patients, clinicians, and hospital and legal systems. This article calls for future research to measure how community power, which includes shifting power to impacted communities to develop and lead equity-focused agendas, is built as both a process and an outcome of MLPs.

Pbpa Creating Pathways To Ensure Patients Are Using Their Inhaled Medications Effectively, Suzan Michelle Collins, Heather Blake, Chandler Blodgett, Sue Vermette, Martine Eon

Operations Transformation

Problem: Patients do not consistently know how to prepare, use and/or clean their inhalers effectively.

Impact: When patients do not consistently know how to prepare, use and/or clean their inhalers effectively they are in fact, not receiving the benefit from their prescribed medication.

They experience poor patient outcomes and overall poor patient experience.

• Increased calls to provider offices for unresolved, worsening symptoms and/or complications. (Thrush, hoarseness, cardiac symptoms etc.)
• Increased same day office visits.
• Patient crowding in Urgent Care and/or Emergency Department.
• Hospital Admissions.
• Increase in emotional and financial stress from missing school and/or work.
• Increase in referrals to specialists …