Patient Safety Commons^™

An Assessment Of Accessibility And Affordability Of Inpatient Psychiatric Care In Tennessee, Kailee Havrda

Electronic Theses and Dissertations

Introduction: Access to mental health has seen changes over the past decade, but little research and attention have been given to access to inpatient psychiatric facilities. Inpatient psychiatric care is crucial for patients experiencing mental health emergencies who need immediate access to care. Gaps in spatial accessibility, affordability, and the access and assessment process were identified due to a lack of available information in the field.

Methods: Secondary data from the Tennessee Department of Health were used to assess financial accessibility through payer source charges and patient encounters, as well as through mapping of inpatient psychiatric facilities and conducting drive …

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.

The Whole Patient: What Fascia Reveals About Pain, Adaptation, And The Case For Treating Together, Kelly Davis Pt, Dpt, Faaompt, Mt

New Orleans Dental Association News

The final piece in this series looks at fascia and the autonomic nervous system — the connective tissue and nerve pathways linking the jaw, neck, and airway into one continuous system — and why both matter to dentistry. Dr. Davis draws on current fascia and pain science research, including work from the 2025 International Fascia Research Congress in New Orleans, to explain how a misaligned bite can travel through this tissue and surface as headaches, how tongue posture and breathwork affect jaw stability, and why complex, chronic cases so often need more than one discipline to make headway. Told partly …

Bridging Awareness And Action: A Multilevel Model Of Organizational Learning, Safety Climate, And Sickle Cell Trait Safety Compliance, Kimberly Snowden

Annual DBA Scholars Conference

Despite the existence of NCAA and National Athletic Trainers’ Association guidelines, preventable sickle cell trait (SCT)-related adverse events continue to occur in athletic settings. This study examines how organizational learning capacity, safety climate, leadership commitment, and individual risk perception influence compliance with SCT safety protocols and related safety outcomes. Drawing on Organizational Learning Theory, Safety Climate Theory, and the Health Belief Model, the study proposes a multilevel framework tested through an explanatory sequential mixed-methods design. Findings are expected to identify organizational predictors of compliance and provide practical recommendations to strengthen SCT safety implementation and reduce preventable athlete harm.

The Anxious Patient: How Breathing, Presence, And Calming Cues Transform What Happens In The Dental Chair, Kelly Davis Pt, Dpt, Faaompt, Mt

New Orleans Dental Association News

In part two of her three-part series for NODA News, Dr. Kelly Davis, PT, DPT, FAAOMPT, MTC, explains why a dentist's own regulation is one of the most powerful tools in the operatory. Dental anxiety triggers a genuine sympathetic nervous system response — elevated heart rate, muscle guarding in the jaw and neck, and a body primed for threat — that makes procedures harder for patient and clinician. Dr. Davis introduces co-regulation, the neuroscience-backed principle that a calm, grounded provider can help settle an anxious patient's nervous system through presence alone. She offers concrete, simple techniques dentists can use before, …

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, …

Breaking The Cycle: From Victimization To Offending Through The Lens Of Human Services, Colette R. Penalosa

Master of Arts in Human Services

The victim-offender overlap challenges the common view that victims and offenders are separately labeled by recognizing that both groups have experienced significant childhood trauma, physical, emotional, and psychological abuse, neglect, and other adverse childhood experiences (ACEs). Current research implies these experiences can increase the risk of offending as they all influence cognitive and behavioral development while leaving criminal behavior undetermined. The purpose of this capstone is to analyze the relationship between childhood victimization and offending from a human service perspective; analyzing the pathways a victim takes on the road to offending. Research conducted will focus on exploring the victim-offender overlap, …

“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 …

Bridging Fiscal Sustainability And Health Equity: A Policy Analysis Of California’S Healthcare Coverage Safeguards, Guadalupe Castaneda Martinez

Master's Projects and Capstones

Without structural policy intervention, approximately 4.6 million Californians remain at risk of being uninsured by 2030, worsening racial and ethnic health disparities and hospital uncompensated care burdens. This policy analysis advocates for a hybrid universal coverage model combining sliding-scale subsidies (California Senate Bill 78) with full-scope Medi-Cal expansion for all income-eligible residents regardless of legal status (California Assembly Bill 133). The framework relies on existing funding mechanisms, including the Managed Care Organization tax and the Health Care Affordability Reserve Fund. Comparative analysis indicates that market-only subsidies leave severe equity gaps, whereas immediate single-payer transitions pose substantial fiscal and administrative risks. …

Medical Tourism Patient Guidance: A Content Analysis Of Risk Reduction Guidelines Available To Global Health Seekers., Alicia Mason, Angela Ashmore

Faculty Submissions

This study examines medical tourism (MT) patient guidance messages intended to reduce procedural risks—those directly related to biomedical treatments—and process risks, which involve logistical, administrative, and interpersonal challenges of seeking healthcare abroad. The analysis focuses on print and digital publications authored by individuals independent of the MT industry, including policy researchers, travel health experts, lifestyle reporters, and consumer-focused medical travel writers. Using a two-phase digital and database search strategy, 27 publications from 2009 to 2024 were identified and analyzed using exploratory content analysis methods. Findings reveal important differences in the scope and depth of guidance aimed at reducing risks for …

Same-Day Cancellation Reduction In An Ambulatory Surgery Unit, Anthone Dalit Vengersammy

Master's Projects and Capstones

Problem: Same-day surgical cancellations in the outpatient surgery setting remain a significant operational and patient care challenge. Preventable cancellations negatively affect patient experience, operating room efficiency, staff productivity, and healthcare costs. 

Context: A microsystem and organizational culture assessment identified several factors contributing to same-day cancellations, including unclear preoperative instructions, incomplete medical clearance, inconsistent patient education, lack of standardized workflows, unclear staff responsibilities, and communication gaps among interdisciplinary teams. SWOT and gap analyses were used to identify opportunities for improvement and guide intervention planning.

Interventions: Quality improvement interventions were implemented through iterative Plan-Do-Study-Act (PDSA) cycles. Strategies included revising preoperative patient instructions, …

Clinical Corner: Pearls From Local Dentists

West Michigan District Dental Society Bulletin

"Clinical Corner: Pearls from Local Dentists" is a section of the WMDDS Bulletin where local dentists share clinical wisdom for fellow practitioners. This edition's topics include Behavior Guidance in Pediatric Dentistry, occupational pain, and occupational hearing loss

Implementation Of A Language-Concordant Follow-Up Protocol To Reduce Percutaneous Nephrostomy Tube Complications: An Evidence-Based Practice Project, Marisol Ornelas

Loma Linda University Electronic Theses, Dissertations & Projects

Purposes/Aims: Complications of percutaneous nephrostomy tubes (PCN) are common after discharge. Language barriers place patients at higher risk for misunderstanding discharge instructions. This evidence-based project evaluated whether a bilingual follow-up protocol three days post-discharge reduces PCN complications in patients.

Methodology: This project utilized the Johns Hopkins Nursing Evidence-Based Practice Model. The project leader reviewed the literature, synthesized the evidence, and developed a standardized PCN discharge training and bilingual PCN follow-up protocol.

Implementation: Unit nurses received training to standardize the PCN discharge process. Nurses educated PCN patients using the standardized process at the time of discharge. Three days …

Comparison Of Selected Supply Chain Management Practices Of Three Major Regional/Metropolitan Hospitals, Alan D. Smith

Atlantic Marketing Association Proceedings

No abstract provided.

Evaluating The Impact Of A Standardized Intimate Partner Violence Screening Tool In A Clinical Setting, Dylan Bogucki

Evidence-Based Practice Project Reports

Intimate partner violence (IPV) is defined as any act of violence, including physical, sexual, stalking, or psychological aggression by an intimate partner, former or current. Despite being preventable, IPV remains a leading nonobstetric cause of morbidity and mortality among women, which highlights the need for systematic screening in clinical settings. The purpose of this quality improvement project is to identify women who have previously experienced or are currently experiencing IPV and to connect them with appropriate resources. Twenty-one studies were identified, all demonstrating moderate to high methodological quality and supporting the need for routine IPV screening in women’s health settings. …

Falling Star Program: A Visual Cue Intervention To Reduce Falls In Long-Term Care, Maggie Shanahan

Evidence-Based Practice Project Reports

Falls among older adults in skilled nursing and long-term care settings remain a leading cause of injury, functional decline, and increased healthcare utilization, contributing significantly to morbidity and mortality in this population (Centers for Disease Control and Prevention [CDC], 2023; Agency for Healthcare Research and Quality [AHRQ], 2022). The primary purpose of this project aimed to implement and evaluate a structured visual cue–based fall prevention intervention to reduce fall rates among high-risk residents in a long-term care facility in Northwest Indiana. The project included 23 participants aged 65 years and older who were identified as high risk for falls. Using …

Staff Educational Impact On School-Based Mental Health Services: A Scoping Review, Daniel J. Kim, Di'yana Fisher, Laura Reed Dnp, Aprn, Fnp-Bc, Cne, Fnap

Doctor of Nursing Practice Projects

Purpose/Background

            Trends are consistently increasing among adolescents in regard to mental health diagnoses and suicide risks, which emphasizes the necessity for early identification via school-based psychiatric screenings. The Patient Health Questionnaire-9 (PHQ-9) has proven effective in uncovering symptoms of depression; variable application and limited staff knowledge continue to be substantial hurdles. This scoping review examined the influence of staff education and training on the efficacy of school-based psychiatric screening.

Methods

            PubMed, CINAHL, Medline, Elsevier, Google Scholar, and JAMA were utilized to conduct this scoping review. Peer-reviewed studies published between 2020 and 2025 were included if they involved adolescents aged 13-18, …

Decreasing Catheter Associated Urinary Tract Infection Through Reinforcement Of Hand Hygiene Compliance In A Rehabilitation Unit, Gloria Ihenwe

Doctor of Nursing Practice Final Project Abstract

Purpose

The purpose of this project is to decrease the CAUTI rate among adult rehabilitation patients with indwelling catheters from 40% to 1% through improved staff hand hygiene (HH) compliance and to increase hand hygiene compliance from 45.24% to 60.47% within 3 months. The secondary aim is that staff will report self-improvement in hand hygiene knowledge and technique.

Background

Catheter-associated urinary tract infections (CAUTIs) are common preventable healthcare-associated infections. Inconsistent HH compliance among direct care staff remains a common challenge and can contribute to infection risks and transmission of microorganisms

Methodology

The Plan-Do-Study-Act (PDSA) quality improvement model guided the implementation …

Digital Touchpoints: Investigating Contact Page Accessibility And Visual Authenticity Within Medical Tourism Health Websites, Alicia Mason, Elizabeth Spencer, Kristen Livingston, Treyton Meyers, Sakshi Bhati, Himika Akram

Faculty Submissions

This study examines two critical digital touchpoints on medical tourism provider (MTP) websites: (1) the accessibility of contact pages which often function as entry points for inquiries, scheduling, and pre-travel coordination, and (2) the authenticity of visual imagery used to shape expectations about care environments, personnel, and technological capacity. A sample of 105 MTPs across all six World Health Organization regions were analyzed using quantitative web accessibility testing and qualitative visual analysis. Results indicate pervasive accessibility errors on contact-page touchpoints and extensive reliance on inauthentic imagery to depict patients, providers, and medical technologies. Together, these practices may distort user expectations …

Can The Implementation Of The Pause Decrease Death Anxiety And Poor Mental Health In Practicing Nurses?, Lilli Meyer

Undergraduate Theses

Practicing nurses are frequently exposed to patient death, placing them at increased risk for death anxiety and compromised mental health. Despite this, there remains a lack of structured, in-the-moment interventions to support emotional processing within clinical settings. This study evaluates whether the implementation of “The Pause,” a brief moment of silence following a patient’s death, may reduce death anxiety and improve mental health outcomes among practicing nurses. A quantitative survey consisting of eight questions was distributed to nurses in the Louisville, Kentucky area over a three-month period, yielding 26 responses. Findings indicated that 80.8% of participants reported no improvement or …

Improving Anesthesia Provider Confidence In The Identification, Management, And Treatment Of Postoperative Delirium, Brittany M. Whistle, Charles Dustin Phelps

Scholars Week

Purpose: Postoperative Delirium (POD) is a potentially devastating complication of anesthesia that is poorly understood by clinical staff leading to poor outcomes for surgical patients. This study is meant to determine if a focused knowledge presentation accompanied by visual aids could increase anesthesia providers confidence in identifying, diagnosing, and treating Postoperative Delirium.

Methodology: Utilizing a statistical model to analyze respondents results on a standardized test administered before and after an informational presentation with visual aids on the topic of Postoperative Delirium.

Results: Results indicated a statistically significant difference between pretest and posttest scores, with a p-value of .002, t(11) = …

Hormonal Birth Control Misinformation On Tiktok: A Content Analysis Of Influencer Narratives, Sarah Bdeir, Jana Hatahet, Liselle Tungol, Khush Hussain, Rumyah Rafique, Raneem Sabbaq, Ragad Almsaddi

Medical Student Research Symposium

Background:

Hormonal birth control is the most common form of reversible contraception. In the U.S., pharmacy data show oral contraceptive pill prescriptions declined 25.6% from March 2021 to October 2023. Meanwhile, patients increasingly seek health information on social media. On TikTok, “hormone hacking” content has surged, often portraying birth control as artificial, harmful, or even carcinogenic, despite a lack of supporting evidence. While accessible information on social media can be valuable, such narratives risk spreading misinformation, fueling mistrust in women’s health.

Methods:

We conducted a qualitative content analysis of 50 TikTok videos (March and September 2025) under #birthcontrol, #hormonehealth, #birthcontroltoxicity, …

Validity And Reliability Of The Wut Hydration System When Assessed In The Afternoon, Peyton A. Hines, Rosie Perez, Rebecca Allen, Shawn Wierick, Xiujing Zhao, Corey Butts, Brendon Mcdermott

2026 Honors Symposium

The WUT (weight, urine color, and thirst) Venn diagram is recommended for individuals to self-assess their hydration status. However, current research is limited to comparisons between morning first-void markers and 24-hour markers. PURPOSE: To examine the validity and reliability of afternoon WUT scores in comparison to 24-hour hydration status. METHODS: Fifty participants (25 ± 8y, 72.2 ± 14.9kg) voluntarily participated in this study. Participants collected afternoon spot urine between 2:00 and 4:00 pm and 24-hour urine samples on three out of seven consecutive days. Body mass (BM), urine color (Ucol), urine osmolality (Uosm), urine specific gravity (USG), and thirst perception …

Use Of A Structured Rounding Model To Improve Interprofessional Communication And Collaboration Among Mds And Rns In A Medicine Unit – An Evidence-Based Practice Project, Jackie Raygoza,

Loma Linda University Electronic Theses, Dissertations & Projects

Purpose/Aims

This DNP project aims to improve communication and collaboration between physicians (MDs) and registered nurses (RNs) on medical units by implementing a structured three-step communication-rounding model integrated into the daily workflow and leveraging existing communication tools. As patients’ conditions become more complex and healthcare demands increase, it is crucial to foster an environment where communication among providers and staff is clear, transparent, respectful, and collaborative. By leveraging information technology and evidence-based strategies, the project seeks to strengthen interprofessional collaboration and improve patient satisfaction and the quality of care. The project includes educational sessions for both MDs and RNs to …

Optimizing Communication In The Periprocedural Area: Implementing Sbar: A Quality Improvement Project, Autumn Chang

Loma Linda University Electronic Theses, Dissertations & Projects

The primary aim of this project is to improve standardized nurse-to-nurse communication at the electrophysiology lab of a large Los Angeles hospital. By providing nursing education on a unit-specific, structured handoff communication framework (SBAR) and incorporating a procedure-specific handoff form for electrophysiology (EP) across pre-, intra-, and post-procedure units, this project aims to improve nurses’ perceptions of the handoff process and the effectiveness of handoff education across the periprocedural units. The project further aims to assess nursing incorporation of the training four weeks post-education and changes in patient satisfaction related to nursing teamwork and communication.

Scrub Up For Success: Transforming Infection Control In Transplant Patients Through Microlearning Video And Poster – A Quality Improvement Project, Wendy Dio

Loma Linda University Electronic Theses, Dissertations & Projects

Introduction and Background

Healthcare-associated infections (HAIs) threaten patient safety, affecting about 1 in 25 hospitalized patients. Clostridium difficile infection (CDI) is a significant contributor, impacting both high-risk groups and the general population. Proper hand hygiene is crucial for preventing CDI transmission. In the U.S., hospital-acquired CDI costs over $1.5 billion annually and causes nearly 500,000 cases and I15,000 deaths each year. California reported 3,526 CDI cases in acute care hospitals, with Loma Linda University hospitals accounting for 16 cases, or 23% of their health system's infection rate.

Methodology

Nurses in the 6A West-Transplant Unit received a PowerPoint presentation on when …

Incidence Of High Volume Residual Gastric Content In Perioperative Patients Taking Glucagon-Like Peptide-1 Receptor Agonists, And Its Dependence On The Duration Of Preoperative Fasting And Drug Holding: A Prospective Observational Study, Marissa Huggins, Ion Hobai

Cumberland Medica

Background: Glucagon-like peptide-1 receptor agonists (GLP-1RAs), including semaglutide and dulaglutide, are increasingly prescribed for type 2 diabetes mellitus and obesity. These agents delay gastric emptying and have been associated with a higher incidence of unexpected full stomachs in procedural patients. To prevent pulmonary aspiration, current recommendations include extending preoperative fasting (e.g., 24 hours instead of the standard 8 hours) and/or withholding the GLP-1RA medication before surgery (≥1 drug half-lives). However, the efficacy of these strategies have remained unclear and are evaluated in this study.

Hypothesis: GLP-1RA use in surgical patients is associated with increased incidence and volume of residual gastric …