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 …

Advanced Practice Provider-Physician Collaboration And Medical Staff Governance: A Framework For Patient Safety, Nicolas Testa, Kaysha Hervey, Cynthia Borum

HCA Healthcare Journal of Medicine

The growth of advanced practice providers (APPs) is occurring in parallel with persistent and projected physician shortages. One important solution and increasingly visible response to these workforce challenges is the expanding role of APPs. Strong physician-APP partnerships can help distribute workload, improve access, and support sustainable practice with the delivery of safe, quality patient care. The future of clinical care will depend on effective APP-physician collaboration grounded in sound credentialing, clearly defined supervision and practice expectations, and robust medical staff monitoring programs. We describe the governance and oversight processes in a large health care system to assess and support APP …

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 …

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.

Care Alert Program In Chronic Emergency Department Using Patients: Expanded Study, Jonathan Leggett, Kaitlyn Phelps, David Nuñez, Brent Wright, Erica Gibbons, Jonathan Bryan, Brian Griggs

HCA Healthcare Journal of Medicine

Introduction

The Care Alert Program (CAP) is designed to help navigate encounters with patients who are high utilizers of Emergency Department (ED) resources. The CAP intends to address the needs of this challenging patient population by designing individualized care plans that are approved by a multidisciplinary committee. The patient populations that frequently use ED resources often have chronic medical conditions, a poor understanding of their conditions, unrealistic expectations regarding treatment, a lack of outpatient resources, and present with multiple complaints when using ED resources.

Methods

The CAP was adopted by our facility in the spring of 2020. The present study …

Ethical Considerations Of Percutaneous Endoscopic Gastrostomy Tube Placement In A Patient With Creutzfeldt-Jakob Disease And Advanced Dementia, Toni Habib, Niamh Siobhán Mulrooney, Yisroel Grabie, Mohammad Maruf, Sophia Kasapira

HCA Healthcare Journal of Medicine

Background

Creutzfeldt-Jakob disease (CJD) is a rapidly progressive neurodegenerative condition that is not easily diagnosed and has no curative treatments available, essentially requiring palliative measures, including tube feeding. Nonetheless, data shows that the endoscope used for percutaneous endoscopic gastrostomy (PEG) tube insertion can be a vector for CJD transmission.

Case Presentation

We discuss the case of an elderly patient diagnosed with CJD, requiring tube feeding. Multiple specialists were consulted, and they were unable to reach an agreement on the best approach. Eventually, the hospital ethics committee intervened, and the family agreed to comfort measures only. This case report sheds light …

Enhancing Patient Safety: The Role Of Interdisciplinary Teams In Reducing Blood Culture Contamination, Austin Patrick Eisenberg, Fady M. Awad, Brian Watson, Mohammed Faris

HCA Healthcare Journal of Medicine

Background

Blood cultures are vital to diagnostic workups among many hospitalized patients, providing valuable information about bloodstream infections (BSIs), which cause roughly 250 000 deaths annually between North America and Europe. Despite advances in health care, blood culture contamination remains a substantial problem, with deleterious effects on patient mortality, patient and hospital costs, and microbial resistance. This article reviews the repercussions of blood culture contamination on the health care system and delineates evidence-based strategies to decrease contamination rates.

Methods

To reduce blood culture contamination rates, our health care facility undertook a quality improvement initiative. A task force was created, consisting …

Inpatient Falls: Epidemiology, Risk Assessment, And Prevention Measures. A Narrative Review, Taylor Locklear, Jeannie Kontos, Callaham A. Brock, Alexander B. Holland, Rachel Hemsath, Anna Deal, Shannon Leonard, Carsten Steinmetz, Saptarshi Biswas

HCA Healthcare Journal of Medicine

Patient falls are a common inpatient dilemma and comprise the largest category of preventable adverse events in hospitalized patients. These events place a clinical burden on the patient, such as increased morbidity and reduced quality of life, in addition to an economic burden on the hospital system. Fall prevention strategies have the opportunity to decrease inpatient health care costs and length of stay. Several risk factors have been identified that contribute to inpatient falls and several strategies have been identified to minimize this risk. These risk factors are typically characterized as intrinsic and extrinsic factors. Intrinsic factors include characteristics such …

Operationalizing A Medication Safety Gap Assessment For A Large Health System, Carley Warren, Joan Kramer, L Hayley Burgess

HCA Healthcare Journal of Medicine

Background

Medication errors continue to be a leading cause of medical errors. In the United States alone, 7000 to 9000 people die annually due to a medication error, and many more are harmed. Since 2014, the Institute for Safe Medication Practices (ISMP) has advocated for several best practices in acute care facilities derived from reports of patient harm.

Methods

The medication safety best practices chosen for this assessment were based on the 2020 ISMP Targeted Medication Safety Best Practices (TMSBP) and health system-identified opportunities. Each month, for 9 months, select best practices were covered with associated tools to assess the …

Dental Care During The Covid-19 Pandemic: Patient Perceptions Of Barriers To Dental Care, Covid-19 Safety Precautions, And Administration Of The Covid-19 Vaccine At The Dental Office, Brunilda Lugo, Sheri Denslow, Jill Fromewick, Scott Davis, Katherine Jowers, J. Amadeo Valdez

HCA Healthcare Journal of Medicine

Background

The Mountain Area Health Education Center (MAHEC) Dental Health Center sought to learn how COVID-19 affected dental care attainment and patient perceptions of appropriate safety measures, as well as their acceptance of the dental office as a site for COVID-19 vaccinations.

Methods

A cross-sectional online survey of dental patients was performed to inquire about barriers to care, safety precautions, including COVID-19 testing, and the acceptability of vaccination for COVID-19 in the dental office. All adult patients of the MAHEC Dental Health Center with an email address on file and a clinic visit in the past year were randomized for …

Quality Of Icu Discharge Summaries Produced By Pediatric Residents: The Memorial Health University Medical Center Experience, Jessica M. Lee, James Ryden, Emma Meehan, Eric Shaw, Mary C. Lytle, Andrew Stack, Ashley Shearman

HCA Healthcare Journal of Medicine

Background

Discharging intensive care unit (ICU) patients directly home is becoming more common. High-quality ICU discharge summaries are crucial in the transition of patient care. Currently, at Memorial Health University Medical Center (MHUMC), there exists no standardized ICU discharge summary template or consistency when discharge documentation is completed. Investigators evaluated the timeliness and completeness of ICU discharge summaries at MHUMC produced by pediatric residents.

Methods

A single-center retrospective chart review of pediatric patients discharged directly from a 10-bed Pediatric ICU to home was conducted. Charts were evaluated pre- and post-intervention. The intervention included the implementation of a standardized ICU discharge …

Unearthing Historical Trauma To Advance Health Equity For Survivors Of Human Trafficking, Sandy Woo-Cater

HCA Healthcare Journal of Medicine

In the last decade, the public health field has grown a strong interest in responding to issues related to human trafficking. This specific concentration in healthcare has made efforts to ensure this work includes culturally appropriate tools to serve patients. While curricula to guide health professionals in areas such as cultural competency, cultural responsiveness, or cultural humility exist, historical trauma is not often integrated in the understanding of health outcomes for patients experiencing human trafficking. This paper asserts that advancing health equity for these patients necessitates a deeper historical perspective.

The Impact Of Covid-19 In The Latinx Community, Laura Pedraza, Ricardo Villela, Vikki Kamatgi, Kaitlyn Cocuzzo, Ricardo Correa, Miriam Zylberglait Lisigurski

HCA Healthcare Journal of Medicine

The COVID-19 pandemic has intensified the existing health and social disparities that affect minority groups in the United States (US), including the Latinx community. This situation has been reflected in many aspects of health, including increased morbi-mortality and reduced adherence to medical and scientific recommendations. Limited access to health care, financial challenges, migrant status, and health literacy, or lack thereof, have all hampered the Latinx community's ability to seek aid quickly and to be tested or treated effectively for this disease. This pandemic has shown that the Latinx community's socioeconomic status correlates with greater mortality rates when compared to other …

Is There A Bias Toward Unvaccinated Covid-19 Patients?, Abbas B. Jama, Anwar Khedr, Hisham Mushtaq, Nitesh K. Jain, Thoyaja Koritala, Syed Anjum Khan

HCA Healthcare Journal of Medicine

With more than 22% of the United States still not vaccinated for COVID-19, we are trying to shed some light on whether there is any bias when treating unvaccinated COVID-19 patients. We highlight several reports where some individuals or organizations displayed possible bias, whether implicit or explicit. We examine the legal and ethical implications of these biases and offer a general overview of how to tackle them.

Pharmacy-Led Medication Reconciliation Program Reduces Adverse Drug Events And Improves Satisfaction In A Community Hospital, L. Hayley Burgess, Joan Kramer, Carley Castelein, Joseph M. Parra, Victoria Timmons, Samantha Pickens, Sarah Fraker, Christopher Cameron Skinner

HCA Healthcare Journal of Medicine

Background

Pharmacy-led medication reconciliation identifies and corrects medication errors that can potentially cause moderate to severe harm. This research sought to identify the impact of pharmacy-led medication reconciliation on patient outcomes and describe the changes in healthcare workers’ perceptions of the program.

Methods

A pharmacy-led admission medication reconciliation program pilot started in July 2019, and a discharge medication reconciliation proof of concept was tested in September 2020 at a 432-bed hospital. The following periods were compared: August 2018 to February 2019 (pre-program implementation) and August 2019 to February 2020 (post-program implementation). Endpoints included patient outcomes, workforce productivity and interdisciplinary healthcare …

Hand Hygiene And Hospital-Acquired Infections During Covid-19 Increased Vigilance: One Hospital’S Experience, Alexander Kong, Carlos S. Botero Suarez, Bebe Rahamatalli, Jennifer Shankweiler, Olga Karasik

HCA Healthcare Journal of Medicine

Background

Hospital-acquired infections are associated with increased morbidity, mortality, costs and length of stay. Prior studies have linked increased hand hygiene compliance with reduced hospital-acquired infection rate. With the increased vigilance for personal and institutional hygiene practices during the COVID-19 pandemic, we hypothesized increased hand hygiene compliance and, as a result, decrease in hospital-acquired infections in our hospital.

Methods

Hand hygiene compliance data was provided by the hospital’s Quality Department. We queried and empirically analyzed local hospital-acquired infection data obtained from our Quality Department and the National Healthcare Safety Network. We compared local hand hygiene compliance rates before and after …

Car Ratings Take A Back Seat To Vehicle Type: Outcomes Of Suv Versus Passenger Car Crashes, Dietrich Jehle, Albert Arslan, Chirag Doshi, Clay O'Brien

HCA Healthcare Journal of Medicine

Background

Car safety ratings are routinely utilized in making automobile purchase decisions. These 1- to 5-star ratings are based on crash test data comparing vehicles of similar type, size and weight.

Objectives

We hypothesized that car safety ratings are less important than vehicle factors such as vehicle type and weight in predicting outcomes of head-on crashes.

Methods

A retrospective study was conducted on severe head-on motor vehicle crashes entered into the FARS (Fatality Analysis Reporting System) database between 1995 and 2010. This database includes all US motor vehicle crashes that resulted in a death within 30 days of the accident. …

Impact Of Order Set Use On Stroke Care, Bilal Nadeem, Edward Waseleski, Meryem Maras-Casey, Sabih Alam, Adnan Faruqui, Michael Gutierrez, Maruthsakhi Molugu, Christina Oricompil, Ashar Mahmood, Katherine Torralba, Fatima Agha, Nour Tlimat, Olu Oyesanmi, Salman Muddassir, Nikolay Mitzov

West Florida Division GME Research Day 2020

A case control study of 118 patients from Oak Hill Hospital between the months of August 2019 and January 2020 was recently completed for a hospital research quality improvement study. The objective was to determine if the use of either Hemorrhagic or Ischemic Stroke Order Set had an effect on the length of stay (LOS) or adherence to current stroke guideline recommendations when compared to its disuse. Results indicate use of either the Hemorrhagic or Ischemic Stroke Order Set led to a decreased length of stay and an increased adherence to current stroke guideline recommendations. Limitations of the study included …

A Comparison Of Models For Evaluation And Transfer Of Patients With Suspected Large Vessel Occlusions, Edward Jauch, Parita Bhuva, Alex Schneider, Jason Thurman, Josh Lewis, Kathryn Mccarthy, Debra Philpot, Robin Jones, Albert Yoo, Don Frei

Neurology

Introduction: Mechanisms for the hospital identification of patients with suspected large vessel occlusions (LVO) vary widely based on referring and receiving stroke center resources. We compared processes for identifying patients with suspected LVO who may be candidates for endovascular therapy (EVT) at non-EVT hospitals and the criteria for interfacility transport to Comprehensive Stroke Centers (CSC) for potential EVT. Methods: Data were obtained from 4 CSC which serve distinct geographic regions, ranging from rural to urban environments, over a continuous 12 month period of time beginning year 2018. Patients transferred from all referring hospitals to these facilities were considered regardless of …

Reinventing The Tradition Of Morbidity And Mortality Conference: Turning Anecdotes Into Databases, Tandis Soltani Md, Key Yan Tsoi Md, Alexandra Csortan, Aidan Charles Md, Darwin Ang

General Surgery

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Demographic Factors, Bmi And Diagnosis That Affect The Administration Of Emergency Treatment Orders In Psychiatric Units, France Leandre Md, Liang Hong, Sarah Fayad Md

Psychiatry

Emergency Treatment Orders (ETOs) are defined by Florida Law as an immediate administration of rapid response psychotropic medications to a person with the purpose of expeditiously treat symptoms that if left untreated, present an immediate danger to the safety of the person or others. Current literature have revealed the effectiveness of psychotropic drugs in treating agitation, however epidemiological studies on this practice are still very lacking.