Patient Safety Commons^™

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 …

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 …

Precision In Practice: Subject Matter Expert Integration To Support Excellence In Population-Specific Documentation, Sara Pump, Mary Hawes, Lauren Spain, Virginia Kasenic, Meagan Talent, Alivia Stewart, Carrin Shaw, Chad Gautreaux, Dori Cousin, Ponesea Allen, Jonathan Rowe

2026

This poster describes a quality improvement initiative that integrated psychiatric resource nurses as subject matter experts (SMEs) into clinical documentation workflows to improve documentation compliance for high-risk behavioral health patients. The intervention resulted in substantial improvements in charting accuracy and compliance, including an increase in emergency department documentation compliance from 28% to 95% over seven months, while enhancing staff education, collaboration, and patient safety.

Patterns And Characteristics Of Incident Reports From Residents: A Single-Center Pilot Study, Atsushi Tanikawa, Tatsuya Ueno, Miyuki Kamitsuma

Health Professions Education

Background Incident reports are essential for identifying patient safety events in hospitals, yet physicians—especially resident physicians—submit relatively few reports. Understanding residents’ awareness and experiences related to patient safety is important for promoting reporting and improving organizational safety.

Methods We conducted a questionnaire-based survey between December 20 and 29, 2020, among resident physicians at a single teaching hospital. The survey evaluated satisfaction with residency training, exposure to patient safety education, understanding of incident reporting, and experiences with submitting incident reports.

Results Of the 16 eligible residents, 15 participated in the survey (response rate: 93.8%), including 10 postgraduate year (PGY)-1 residents and …

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. …

Bridging The Language Gap: The Impact Of In-Person Versus Remote Interpreter Services On Medication Adherence And Patient Safety In Adult Spanish-Speaking Patients, Ashley E. Alarcon Martinez, Jocelyn N. Lopez Maradiaga

Nursing | Student Research Posters

Background: Significant health inequities are caused by language barriers between patients and health care staff, resulting in miscommunication among adult Hispanic patients with low English proficiency, reducing medication adherence, impairing patient safety, and raising the possibility of medical errors. To address this issue, interpreter services, both in-person and remote translation, have been introduced in healthcare settings to enhance communication. Objective: The purpose of this study is to investigate the differences in patient safety and medication adherence between in-person and remote translation services for adult Hispanic individuals with limited English proficiency in healthcare settings. Methods: The proposed research involves five local …

Factfinders For Patient Safety: Minimizing Complications In Radiofrequency Neurotomy: Part I-Implantable Devices; Part Ii-Preprocedural Bvnrfn Imaging, David Hao, Gerald Yeung, Haewon Lee, Zheyan Chen, Ben Laplante, Paul Kitei, Reza Ehsanian, David Levi

Moss-Magee Rehabilitation Papers

This series of FactFinders presents a brief summary of the evidence and outlines recommendations regarding minimizing risks with radiofrequency neurotomy procedures. The evidence in support of the following facts is presented: (1) While data on the safety of radiofrequency neurotomy in patients with implanted devices are limited, the procedure can likely be performed safely with careful adherence to best practices and manufacturer recommendations. (2) Basivertebral nerve radiofrequency neurotomy can be performed safely and effectively at the L3 through S1 vertebral levels. Scrutiny of preprocedural imaging may minimize risk. Although the transpedicular approach is preferred, patient anatomy may dictate a non-transpedicular …

Failure To Rescue After Surgery For Pancreatic Cancer: A Systematic Review And Narrative Synthesis Of Risk Factors And Safety Strategies, Masashi Uramatsu, Yoshikazu Fujisawa, Paul Barach, Hiroaki Osakabe, Moe Matsumoto, Yuichi Nagakawa

College of Population Health Faculty Papers

Background: Failure to rescue (FTR), defined as death after major postoperative complications, is a critical quality indicator in pancreatic cancer surgery. Despite advances in surgical techniques and perioperative care, FTR rates remain high and vary across institutions. Methods: This systematic review uses a narrative synthesis followed by PRISMA 2020. A PubMed search (1992-2025) identified 83 studies; after screening, 52 studies (2010-2025) were included. Eligible designs were registry-based, multicenter, single-center, or prospective audits. Given substantial heterogeneity in study designs, FTR definitions, and outcome measures, a narrative synthesis was performed; no formal risk-of-bias assessment or meta-analysis was conducted. Results: …

Glucometer Cleanliness On A Neuro-Medical Intensive Care Unit, Abbey Camire

Operations Transformation

Glucometers on the Neuro-Medical ICU are being docked with visible reddish/brown residue, indicating they are not properly cleaned beforehand. This poses a risk of transmitting pathogens, endangering patient and staff safety, and violates hospital policy and regulatory standards. Proper disinfection of mobile medical equipment is essential for infection control and hospital accreditation.

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 …

Analyzing And Mitigating The Risks Of Patient Harm During Operating Room To Intensive Care Unit Patient Handoffs., Nara Regina Spall Martins, Edson Zangiacomi Martinez, Cláudia Marquez Simões, Paul Barach, Maria José Carvalho Carmona

SKMC Student Presentations and Publications

Patients continue to suffer from preventable harm and uneven quality outcomes. Reliable clinical outcomes depend on the quality of robust administrative systems and reliable support processes. Critically ill patient handoffs from the operating room (OR) to the intensive care unit (ICU) are known to be high-risk events. We describe a novel perspective on how risk factors associated with the process of patient handoff communication between the OR and the ICU can lead to flawed communication, degraded team awareness, medical errors, and increased patient harm. Data were collected from two semi-structured focus groups using a five-step risk management approach at a …

Health Matters! Coloring And Activity Booklet (16-Pages), Your Very Favorite, Children's Health, Lorraine Sheldon, May Bressler

English

Health Matters! is a English-language health literacy resource designed for pediatric patients and their families. Written at an approximately 6th-grade reading level, it supports patient education through engaging coloring and activity pages.

This booklet version includes a smaller selection of materials from the larger Health Matters! book. Developed for use in both hospital settings and the broader community, the resource promotes learning through interactive, age-appropriate activities.

This printable PDF version contains the complete collection of activities and comprises 16 pages. The resource was commissioned by Children's Health and prepared by Your Very Favorite.

Central Line, Your Very Favorite, Children's Health

English

single-page

Hand Hygiene, Your Very Favorite, Children's Health

English

single-page

Foley Catheter, Your Very Favorite, Children's Health

English

single-page

Hospital Safety, Your Very Favorite, Children's Health

English

two-pages

Hospital Safety, Your Very Favorite, Children's Health

English

11x17 page

Personal Protective Equipment, Your Very Favorite, Children's Health

English

single-page

Transmission-Based Precautions, Your Very Favorite, Children's Health

English

single-page

Central Line (Spanish), Your Very Favorite, Children's Health

Spanish

single-page, Spanish

Foley Catheter (Spanish), Your Very Favorite, Children's Health

Spanish

single-page, Spanish

Hand Hygiene (Spanish), Your Very Favorite, Children's Health

Spanish

single-page, Spanish

Hospital Safety (Spanish), Your Very Favorite, Children's Health

Spanish

two-pages, Spanish

Hospital Safety (Spanish), Your Very Favorite, Children's Health

Spanish

11x17 page, Spanish

Personal Protective Equipment (Spanish), Your Very Favorite, Children's Health

Spanish

single-page, Spanish

Transmission-Based Precautions (Spanish), Your Very Favorite, Children's Health

Spanish

single-page, Spanish

Health Matters! Coloring And Activity Book (80-Pages), Your Very Favorite, Children's Health, Lorraine Sheldon, May Bressler

English

Health Matters! is a English-language health literacy resource designed for pediatric patients and their families. Written at an approximately 6th-grade reading level, it supports patient education through engaging coloring and activity pages.

The content covers a wide range of health and wellness topics, including body systems, nutrition, mental wellness, patient safety, and social-emotional skills such as building friendships and navigating conversations when returning to school. Developed for use in both hospital settings and the broader community, the resource promotes learning through interactive, age-appropriate activities.

This printable PDF version contains the complete collection of activities and comprises 80 pages. The resource …

La Salud Es Importante: Libro De Actividades (16-Pages), Your Very Favorite, Children's Health, Lorraine Sheldon, May Bressler

Spanish

Health Matters! is a Spanish-language health literacy resource designed for pediatric patients and their families. Written at an approximately 6th-grade reading level, it supports patient education through engaging coloring and activity pages.

This booklet version includes a smaller selection of materials from the larger Health Matters! book. Developed for use in both hospital settings and the broader community, the resource promotes learning through interactive, age-appropriate activities.

This printable PDF version contains the complete collection of activities and comprises 16 pages. The resource was commissioned by Children's Health and prepared by Your Very Favorite.

La Salud Es Importante: Libro De Actividades (80-Pages), Your Very Favorite, Children's Health, Lorraine Sheldon, May Bressler

Spanish

Health Matters! is a Spanish-language health literacy resource designed for pediatric patients and their families. Written at an approximately 6th-grade reading level, it supports patient education through engaging coloring and activity pages.

The content covers a wide range of health and wellness topics, including body systems, nutrition, mental wellness, patient safety, and social-emotional skills such as building friendships and navigating conversations when returning to school. Developed for use in both hospital settings and the broader community, the resource promotes learning through interactive, age-appropriate activities.

This printable PDF version contains the complete collection of activities and comprises 80 pages. The resource …