Patient Safety Commons^™

The Utilization Of Uv-C Devices To Improve Cleaning And Disinfection In The Operating Room For Reduction Of Infection Rates: An Integrative Research Review (Irr), Kathrina Joyce L. Manalo

Covenant Nurses Week 2026

No abstract provided.

Decreasing Hospital Acquired Pressure Injuries Through A Multi-Intervention Approach: A Quality Improvement Project, Kendra D. Crawford

DNP Scholarly Projects

BACKGROUND: Hospital acquired pressure injuries (HAPIs) continue to plague hospitals across the country. HAPIs are an indication of the quality of care delivered by the hospital’s nursing workforce. These injuries are costly to organizations and can lead to increased length of stay (LOS). The development of a HAPI, depending on severity, is a reportable injury and is classified as patient harm. Patients who suffer from HAPIs can experience significant pain and at times, permanent disfigurement. This project’s focus is a community hospital that has seen a steady increase in HAPIs over the last 2 years. During 2025, 28% of the …

Developing An Educational Session And Epic-Based Tools To Help Nurses Provide Culturally Sensitive Care To Their Muslim Patients, Laila Albutmeh

Nursing | Senior Theses

Background: Islam is currently the fastest growing religion in the world and the chances of nurses having a Muslim patient is exceptionally high yet many nurses lack the knowledge and resources on how to accurately provide culturally sensitive care to Muslim patients. Hospitals lack educational sessions/training as well as Epic tools to help nurses provide culturally sensitive care to Muslim patients which leads to a knowledge deficit in cultural sensitivity of Islamic beliefs, values, and practices. Purpose: This thesis paper proposes a research design for a nurse education/training program on Islamic beliefs, values, and practices along with an implementation of …

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.

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.

No Pass Culture Lowers Patient Fall Incidence, Marie Camille Austria

Covenant Nurses Week 2026

No abstract provided.

Improving Patient Outcomes Through Structured Nursing Surveillance In Acute Stroke And Transient Ischemic Attack (Tia): An Integrative Research Review (Irr), Sheeba Everard Matthew

Covenant Nurses Week 2026

No abstract provided.

Improving Patient Outcomes Through Structured Nursing Safety Huddles In Acute Care Settings: An Integrative Research Review (Irr), Brandon Everard Thomas

Covenant Nurses Week 2026

No abstract provided.

Higher Nurse-To-Patient Staffing Ratios Affect Patient Safety Outcomes: An Integrative Research Review (Irr), Kimberly Everard Martinez

Covenant Nurses Week 2026

No abstract provided.

Hapi Heroes Initiative: Innovating Patient Turn Strategies Utilizine The Braden Scale To Prevent Hospital Acquired Pressure Injuries (Hapi) In The Cardiac Telemetry Unit-A Reposition Disposition Quality Improvement Project, Kenn Everard Lachenal, Kimberlea Gale Hiett-Gonzales, Charmaine Capili, Jelly Jacob, Melissa Fallorina, Dillon Mckee

Covenant Nurses Week 2026

No abstract provided.

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 …

Implementing A Standardized App-Led Multidisciplinary Medication Review And Reconciliation To Improve Medication Safety Before Systemic Cancer Therapy: An Ambulatory Oncology Quality Improvement Initiative, Sarah R. Hines

DNP Projects

Background

Adult patients initiating systemic cancer therapy frequently present with pre-existing polypharmacy related to chronic comorbidities and cancer-related symptom management. The addition of anticancer therapies and supportive care medications further increases medication burden and the risk of medication-related harm. Although national organizations and institutional policies recommend comprehensive medication review before treatment initiation, implementation remains inconsistent in ambulatory oncology practice.

Purpose

To implement and evaluate a standardized Advanced Practice Provider (APP)-led multidisciplinary medication review and reconciliation process designed to identify medication medication-related safety risks before initiation of systemic cancer therapy in adult oncology patients receiving care in an ambulatory infusion center. …

Increasing Documentation Of Endotracheal Tube Cuff Pressures: A Quality Improvement Initiative For Flight Crew Providers, Matthew D. Noss

Graduate Theses, Dissertations, and Problem Reports (ETD)

ABSTRACT

Background: There was a lack of documentation of endotracheal tube (ETT) cuff pressures (CPs) by flight crew providers at Base 1 of HealthNet Aeromedical Services. A three-month pre-intervention data collection showed 1.8% of patients had initial CPs documented. Inadequate documentation and monitoring of ETT CPs can lead to patient complications such as tracheal injury and aspiration making this an important area for quality improvement.

Purpose: To increase documentation of ETT CPs through education and evidence-based interventions.

Intervention: This project implemented an educational in-service on ETT cuff syringe manometry for flight crew providers. The educational intervention consisted of …

Lost In Translation: How Health Literacy Impacts Pharmaceutical Transactions From Healthcare Professionals To Patients, Grace Nwaege

2025 Fall Honors Capstones Projects - Archive

Health literacy is a core element of public health, involving the ability to access, understand, evaluate, and use information to maintain well-being. In the United States, it aligns with an average reading level of about an eighth grader, which continues to decline over time. As pharmacists serve as the final point of contact in most outpatient settings, their ability to communicate effectively at this literacy level is crucial. This study examines how pharmacies address this challenge using qualitative methods, including health literacy assessments of patient consent forms and stakeholder interviews with pharmacy technicians about resource use. Findings show materials higher …

Developing Nlp-Based Open-Source Tools To Improve Titratable Infusion Order Interpretation In Ehr Systems, Benjamin Brewer, Jay Dorris

Student Scholar Symposium

This study evaluates the feasibility of using natural language processing (NLP) tools to identify errors in titratable infusion orders for Joint Commission readiness. Titratable infusions are adjusted at the bedside by nurses based on predefined parameters, such as monitoring goals, titration rate, conditions for adjustment, and maximum dose. These parameters are often documented as free text within order sets but can be inadvertently removed during the verification process. Some electronic health records (EHRs) may not prominently display this critical information, leading to potential Joint Commission violations. A synthetic dataset was generated using artificial intelligence to simulate one year’s worth of …

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. …

Exploring The Prevalence And Determinants Of Self-Medication During Pregnancy Among Women From South Punjab, Pakistan, Madiha Madiha, Sehar Jabbar, Imran Masood

Makara Journal of Health Research

Background: For developing countries with high neonatal and maternal mortality rates, any practice that may threaten the maternal-fetal health must be gauged. This study evaluated the prevalence and contributing factors of self-medication during pregnancy among women opting for antenatal or postnatal care in South Punjab, Pakistan.

Methods: A cross-sectional study design was used. Data was collected from 424 women, selected through multi-stage sampling, who visited health care facilities located in six randomly selected cities of South Punjab. Outcomes reported by descriptive and inferential statistics (p < 0.05). Binary logistic regression analysis was performed to determine the association of self-medication with different factors.

Results: Most of the women were involved in self-medication practice (38.9%) …

Violence Between Residents In Nursing Homes Is An Enduring Problem. The Agencies, Nursing Homes, And Residents Are Playing Hot Potato With The Responsibility, Cindy Marchionda, Rafael Escalara Montoto

Capstones

Resident-to-resident aggression in nursing homes is a persistent issue, far more common than the general public realizes. While many of these violent situations can be managed, some tragically escalate to fatal outcomes, leaving families mourning the loss of their loved ones at the hands of a facility that was meant to provide safety and care during their final years. Experts agree that this issue is largely driven by chronic understaffing and insufficient training for employees on how to manage patients with dementia and aggression issues.

Emergency Preparedness Education And Simulation Training For Nursing Students In Southern India, Kevin C. Cameron, Taryn Mccoy, Laura Gray, David Phillippi

DNP Projects

Introduction

To address the identified gap in emergency preparedness education and training among nursing students at a teaching hospital in southern India, a private university in the southeastern United States partnered with the site to develop a quality improvement initiative aimed at strengthening these skills. Nursing students at the partner hospital have limited access to simulation-based training opportunities due to constraints in both curriculum and availability of simulation resources. This lack of exposure may hinder the development of critical emergency preparedness competencies

Methods

Educational content focused on triage and basic life support (BLS). One hundred twenty-four students participated in the …

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% …

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 …

Best Practice Recommendations For Anesthesia Providers In Preventing Postoperative Delirium In The Geriatric Population Undergoing Non-Cardiac Surgery, Ana Primeaux, Ashanti Reed

Doctoral Projects

Postoperative delirium (POD) is a significant and preventable complication in geriatric patients undergoing non-cardiac surgery. Such complication is associated with foreseeable consequences, such as prolonged hospitalization, long-term cognitive decline, increased morbidity and mortality, and increased costs. Despite the emerging awareness of evidence-based nonpharmacologic and pharmacologic interventional strategies, POD still represents a clinical challenge for anesthesia providers.

Currently, there is a lack of clinical guidelines to guide formalized education and evidence-based interventions on POD prevention across anesthesia practice settings. Consequently, there is a critical need to raise awareness that the lack of clinical guidelines and the high incidence of POD may …

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 …

Prevalence Of Potentially Inappropriate Medications In People Living With Hiv: A Systematic Review And Meta-Analysis, Mustapha Muhammed Abubakar, Abdulmuminu Isah, Ruth Jeminiwa, Ibraheem Abioye, Ismaeel Yunusa, Mohammed Abba-Aji, Osagie Kenneth Cole, Jamila Sani, Mukhtar Ijaiya, Chukwuemeka Nwachuya, Yusuf Ibrahim, Mustapha Usman, Duke Daniels, Oluwaseun Samuel Ilugbuhi, Blessing Onyinye Ukoha-Kalu

College of Pharmacy Faculty Papers

BACKGROUND: Potentially inappropriate medications (PIM) are associated with adverse health outcomes. The use of PIM among persons living with HIV (PLHIV) could be more problematic due to peculiarities such as antiretroviral toxicity and drug-disease interactions. However, PIM among PLHIV continues to receive little attention. Therefore, we aimed to systematically review and estimate the prevalence of PIM among PLHIV.

METHODS: We searched the PubMed, Scopus, and Web of Science databases to identify relevant studies from 1 January 2014 to 30 June 2024. Studies included were peer-reviewed articles that determined PIM prevalence using validated explicit or implicit tools and provided statistical information …

Assessing The Role Of Social Media As A Complementary Source In Pharmacovigilance: Insights From Faers, X (Formerly Twitter), And Askapatient Data Across Multiple Drug Classes, Nwanneka Okere

Dissertations

Background: Adverse drug reactions (ADRs) pose significant public health challenges yet remain substantially underreported in traditional pharmacovigilance systems. Social media platforms and patient-reported outcome forums have emerged as potential complementary sources for capturing real-time patient experiences with medications, but their integration with established surveillance systems remains underexplored.

Purpose: This study examined ADR reporting patterns across FDA Adverse Event Reporting System (FAERS), X (formerly Twitter), and Askapatient to evaluate whether patient-generated digital data can complement traditional pharmacovigilance systems for enhanced drug safety monitoring.

Methods: An explanatory sequential mixed-methods design analyzed 107,753 reports representing 289,740 individual ADR occurrences for …

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 …

N Y State Dent J November 2025

The New York State Dental Journal

In the November 2025 issue, the reader will find the following feature articles:

• "Attitudes of New York State Pediatric Dentists Toward Treating Hasidic Patients"
• "A Qualitative Assessment of the Role of Dental Specialists in U.S. Opioid Epidemic"
• "Revolutionizing Dental Operatories"
• "An Update on Non-Cigarette Nicotine-Containing Products and the Periodontal Patient"

This issue includes regular columns with regional news impacting the New York membership including: editorial and legal columns, association activities, component news, continuing education opportunities, and classifieds.

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: …

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 …

Delayed Diagnosis Of Systemic Lupus Erythematosus Presenting As Autoimmune Hemolytic Anemia: A Case For Heightened Clinical Suspicion, Diana Acosta Pozo, Luis Álvarez Pérez

Research Colloquium

Background: Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease characterized by multisystem involvement, including hematologic manifestations. Autoimmune Hemolytic Anemia (AIHA), though an established feature, is relatively uncommon and may occur early or in isolation. When AIHA presents without overt systemic symptoms, the underlying autoimmune etiology may be overlooked, resulting in delays in diagnosis and treatment. Prompt recognition is essential to prevent unnecessary interventions and prolonged morbidity.

Case Presentation: A 39-year-old woman residing in Texas presented to the Rheumatology office with persistent synovitis and severe transfusion-dependent anemia, requiring red blood cell transfusions every 48 hours for over three months. She …