Patient Safety Commons^™

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 …

“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 …

Improving Structured Handoff Documentation In A Pediatric Emergency Department, Deborah Hammett, Rebecca Matta, Jody Kieffer, Jillian Savage, Courtney Nelson

Department of Pediatrics Faculty Papers

INTRODUCTION: The I-PASS handoff tool guides provider handoffs and reduces adverse events in the inpatient setting. Transitions of care occur frequently in the emergency department (ED), and the unpredictable environment can lead to less structured handoffs. Our goal was to increase the percentage of handoff notes that include all 4 I-PASS components by 20% within 6 months.

METHODS: We developed a handoff note template for the pediatric ED that included 4 key I-PASS elements: illness severity, patient care summary, action list, and situational awareness/contingency planning. Our primary outcome measure was the percentage of handoff notes that contained all 4 I-PASS …

Assessment Of Emergency Medicine Residents' Situational Awareness And Perception Of Patient Safety Culture In The Emergency Department, Adriana Olson, Nathan Olson, Nicholas Hartman, Casey Morrone, Morgan Battaglia, Kamna Balhara

Department of Emergency Medicine Faculty Papers

BACKGROUND: Situational awareness (SA) and positive safety climate are crucial to patient safety. Little is known about emergency medicine (EM) trainees' SA and perception of emergency department (ED) safety climate, and the interactions of those factors with safety-related behaviors.

OBJECTIVES: Our objective was to evaluate EM residents' perceptions of ED safety climate, self-reported SA, and comfort with identifying, rectifying, and reporting safety hazards.

METHODS: In this cross-sectional study at two EM residencies, residents completed the Situational Awareness Rating Technique (SART) after ED-based or simulated resuscitations as well as a survey regarding safety climate and comfort with identifying, rectifying, and reporting …

Standardization Of Discharge Instructions For Mild Traumatic Brain Injury/Concussion In Children Presenting To Ed: A Qi Project, Niralee K. Rana, Nicole Gerber, Michael Alfonzo, Snezana Osorio, Deborah Levine

Rowan-Virtua Research Day

Background: Mild traumatic brain injuries (mTBI) or concussions account for high rates of emergency department (ED) visits. Concussion diagnoses are used less often in young children leading to a variability in parental education and discharge instructions. Lack of discharge guidance may increase parental anxiety, impact recovery, and increase ED visits.

Objectives: To increase the proportion of ED patients discharged with age-appropriate instructions for mTBI by 50% by June 1, 2024, and to determine the impact age-appropriate instructions have on decreasing parental anxiety.

Methods: This observational time series with planned sequential experimentation is in progress at a Pediatric ED affiliated with …

Using Education To Confidently Identify And Report Concerns Of Child Abuse And Neglect: A Qualitative Improvement Initiative Through Staff Development, Sarah E. Neilson

Master's Theses and Capstones

BACKGROUND: Pre-licensure education on child abuse and neglect is crucial for nurses in the healthcare field. It helps to equip them with the knowledge and skills necessary to effectively identify, report, and intervene in cases of child abuse and neglect. Having this education available and understanding the signs and effects of child abuse and neglect, empowers nurses to take quick and decisive action in early intervention and prevention. Within the microsystem of a local Operating Room (OR), this quality improvement (QI) project will determine the muchneeded addition to the healthcare curriculum.

METHODS: The Plan, Do, Study, Act (PDSA) framework was …

Oxygen Therapy Education To Improve Oxygen Safety In The Emergency Department: A Quality Improvement Project, Latania Wolfe

DNP Projects

Background and Significance: Oxygen is often administered in emergency departments (ED) in US without the nurses and other healthcare staff inputting orders for this medication. This gap in placing orders poses a risk to patient safety and poses a regulation issue.

Purpose: The goal of this quality improvement project is to increase the rate of orders placed for patients using oxygen in ED staff by 12% from March 1, 2023 to May 31, 2023.

Methods: The Model for Improvement guided this quality improvement project. Two PDSA cycles were completed.

Results: PDSA #1 Completed SWOT analysis and used information to …

Experiential Learning In Patient Safety: A Multi-Center Study Examining Emergency Medicine Residents' Situational Awareness Of Hazards Via Simulation, Kamna S Balhara, Nathan Olson, Jessica L Wilson, Rosemarie G Ramos, Harlan J Goode, Andrew E Muck, Adriana S Olson

Faculty, Staff and Student Publications

Introduction The 2016 Clinical Learning Environment Review established that experiential patient safety curricula for residents are uncommon. Moreover, these curricula do not incorporate non-technical skills linked to safety, such as situational awareness (SA). We developed an in-situ patient safety simulation exercise incorporating core SA concepts and subsequently assessed exercise feasibility and acceptability, and measured residents' safety SA. Methods A simulation scenario and mock chart were designed, incorporating 16 patient safety hazards. Residents at two institutions reviewed the chart and had 10 minutes in an emergency department room with the simulated scenario to document identified hazards, followed by a facilitated debriefing. …

Utilization Of Acupuncture Services In The Emergency Department Setting: A Quality Improvement Study, John R. Burns, Jessica J. F. Kram, Vashir Xiong, Jeanne M. Stark Casadont, Tiffany A. Mullen, Nancy Conway, Dennis J. Baumgardner

Journal of Patient-Centered Research and Reviews

Purpose: Patients often present to the emergency department (ED) for pain. As opioid fatalities rise, alternative treatments are warranted for pain management. Acupuncture, a nonpharmacological treatment involving the insertion of needles into skin or tissue at specific points within the body, may help to decrease acute pain. Our study aimed to assess the utilization and impact of acupuncture in the ED for acute pain management.

Methods: We conducted a retrospective analysis of purposefully collected quality improvement data. Patients who were ≥18 years old and who presented to the ED at an urban medical center in Wisconsin during 2017 were offered …