Classics and Emerging Classics

This cross-sectional study examined associations between safety culture, missed nursing care, and adverse events. Investigators found significant associations between worse ratings of safety culture and more reports of missed nursing care. They recommend enhancing safety culture to reduce missed nursing care and improve safety.

This book explores how advancements in technology can improve decision making but may also diminish patient-centered care. The author discusses the potential of big data, artificial intelligence, and machine learning to enhance diagnosis and care delivery. A past PSNet interview with the author, Eric Topol, talked about the role of patients in the new world of digital health care.

Artificial intelligence (AI) technologies can improve the use of data in care delivery. This review recommends steps to enhance the use of AI in bedside care. The author highlights the need for clinicians to accept that AI tools will affect care processes and be trained to participate in AI integration on the front line.

Duty hour reform for resident physicians was implemented as a patient safety measure, but it remains controversial. The iCOMPARE study is a cluster-randomized noninferiority trial in which 63 internal medicine programs were assigned either to follow the 2011 duty hour rules or to maintain flexible resident schedules. Researchers found no significant differences in 30-day mortality or AHRQ patient safety indicators among programs with fixed versus flexible resident schedules, similar to a recent study of surgical trainees. Programs with flexible schedules had slightly higher 30-day readmission rates and higher incidence of prolonged length of stay. Overall, the authors conclude that local flexibility in resident schedules did not adversely affect patient safety. An accompanying editorial calls for eliciting patient perspectives about trainee duty hours and the therapeutic relationship between rotating physicians and the hospitalized patient. A previous PSNet interview discussed the FIRST trial, which examined how less restrictive duty hours affected patient outcomes and resident satisfaction.

This cluster-randomized trial compared an internal medicine residency schedule that adhered to 2011 duty hour regulations to a flexible schedule that maintained an overall 80-hour work week. Self-reported sleepiness and measured sleep duration did not differ by group, but residents in the flexible programs performed worse on psychomotor vigilance testing, a measure of alertness. The authors recommend implementing fatigue-management training during residency.

Timely and accurate diagnosis is a prerequisite for safe and high-quality treatment. This study used data from the Human Diagnosis Project (Human Dx, an online case-solving platform) to examine diagnostic accuracy among individual physicians compared to groups of physicians (collective intelligence). Physicians can enter cases onto the platform or solve cases that others have entered. The more physicians involved in solving a given case, the more likely that the correct diagnosis would be identified. Groups of physicians across specialties outperformed individual subspecialists even for subspecialty-relevant cases. The authors advocate for testing the use of collective intelligence for diagnosis in clinical settings. A related editorial discusses how teaching diagnosis has evolved and the possibility of using collective intelligence to improve diagnostic accuracy. In a previous PSNet interview, Shantanu Nundy, Director of Human Dx, discussed his work with the project.

This retrospective cohort study found that adolescent patients who received opioids for surgical and dental procedures were more likely to develop persistent opioid use if they had family members with long-term opioid use. The study team recommends preoperative screening for long-term opioid use in family members as part of prescribing decision-making for adolescent patients.

Overuse of unnecessary tests and procedures contributes to patient harm. In this cohort study, researchers found that patients who developed a hospital-acquired condition after undergoing a procedure that most likely should not have been performed had longer lengths of stay than patients who did not develop a hospital-acquired condition.

Scheduling overlapping surgeries has raised substantial patient safety concerns. However, research regarding the impact of concurrent surgery on patient outcomes has produced conflicting results. In this multicenter retrospective cohort study, researchers examined the relationship between overlapping surgery and mortality, postoperative complications, and surgery duration for 66,430 surgeries between January 2010 and May 2018. Although overlapping surgery was not significantly associated with an increase in mortality or complications overall, researchers did find a significant association between overlapping surgery and increased length of surgery. An accompanying editorial discusses the role of overlapping surgery in promoting the autonomy of those in surgical training and suggests that further research is needed to settle the debate regarding the impact of overlapping surgery on patient safety.

Breakdowns in communication and teamwork are common contributors to adverse events and can compromise safety. As medical care becomes more complex, more teams and subspecialists are involved in a patient's care, which may lead to fragmentation of care and a lack of clear ownership. This three-part series on teamwork highlights the challenges surrounding interprofessional communication and collaboration in today's health care environment, with an emphasis on the resultant adverse effects for patients. The first commentary describes a scenario in which many consultants were carefully considering a patient's case but were not communicating effectively with one another. The second commentary underscores how psychological safety can facilitate improved collaboration and error disclosure among teams. In the third part of the series, the author points out that although the practice of medicine is highly dependent on effective teamwork, medical culture continues to emphasize and even heroize the individual to its own detriment. The author suggests that further research is necessary to achieve optimal teamwork in medicine. A PSNet interview discussed the importance of leadership and teamwork in health care.

Hospital-acquired pressure ulcers are considered never events and represent a significant source of patient harm. This systematic review and meta-analysis found a pooled incidence of 12% for pressure injuries related to the use of medical devices.

Researchers assessed the effectiveness of the Food and Drug Administration (FDA) Risk Evaluation and Mitigation Strategy in preventing inappropriate prescribing of transmucosal immediate-release fentanyl, high-risk opioid products with narrow prescribing indications. Survey data obtained from patients, providers, and pharmacists at various points after the FDA program's initiation suggested ongoing misunderstanding regarding appropriate prescribing. Analysis of claims data 5 years into the program revealed that anywhere from 35% to 55% of patients were prescribed transmucosal immediate-release fentanyl products inappropriately.

Effective teamwork and communication are critical to ensuring patient safety in the busy environment of the operating room. This review examined the evidence on preparing staff to challenge authority in the perioperative environment. Common themes that affect speaking up included hierarchy, organizational culture, and education. Teaching that promotes open communication in the postgraduate environment and utilizing tactics such as simulation training can help address barriers to challenging authority.

Risk aversion in clinical practice may lead to the ordering of unnecessary tests and procedures, a form of overuse that may pose harm to patients. Experienced clinicians may be more comfortable with uncertainty and risk than less experienced providers. In this cross-sectional study, researchers surveyed doctors working in three emergency departments to understand their level of experience and used vignettes to characterize their reactions to uncertainty and risk. They found a significant association between more clinical experience and less risk aversion as well as a significant association between more experience and greater ease with uncertainty. The authors caution that they cannot draw conclusions on how these findings impact patient safety. An accompanying editorial suggests that feedback is an important mechanism for improving confidence in clinical decision-making. A WebM&M commentary discussed risks related to overdiagnosis and medical overuse.

Artificial intelligence may have the potential to improve patient safety by enhancing diagnostic capability. In this study, researchers applied machine learning techniques to a large amount of pediatric electronic health record data and found that their model was able to achieve diagnostic accuracy analogous to that of skilled pediatricians.

The degree to which sepsis contributes to inpatient mortality and the extent to which sepsis-associated inpatient mortality is preventable remains unknown. In this retrospective cohort study, researchers analyzed the medical records of 568 adult patients hospitalized at 6 United States hospitals who either died during the hospitalization or were discharged to hospice. They found a diagnosis of sepsis was present in 300 cases and that it was the main cause of death in 198 cases. Reviewers rated 11 of the 300 sepsis-associated deaths as definitely or moderately likely preventable. The authors conclude that it may be challenging to further reduce sepsis-associated inpatient mortality.

Maternal harm is a sentinel event that has garnered increased attention in both policy and clinical environments. This qualitative study combined direct observation and interviews to understand the characteristics that enabled a high-performing maternity ward to achieve their excellent safety outcomes. Investigators identified a set of specific, evidence-based safety practices including standardization, monitoring, and emphasis on technical skill. They also identified a strong and consistent safety culture and noted that structural conditions, such as staffing levels and the physical environment, supported safe outcomes. The authors conclude that all of these factors influence each other and jointly produce safety. A recent Annual Perspective summarized national initiatives to improve safety in maternity care.

Safe diagnosis is a complex challenge that requires multidisciplinary approaches to achieve lasting improvement. Effective feedback is a primary component of individual, team, and organizational learning. This commentary describes how creating pathways within an organization that enable physicians to provide and receive feedback about diagnostic performance can limit overdiagnosis and overuse.

Reducing opioid-related harm is a major patient safety priority. This simulation study used a mathematical model to predict the effect of existing opioid misuse interventions on opioid overdose mortality. The researchers compared the expected decline based on the current trend over time versus the effect of a 50% faster reduction in misuse. Their calculations suggest that interventions such as prescription drug monitoring programs and insurance coverage changes will result in only a small absolute decrease in opioid overdose deaths. The authors call for developing and testing other strategies for opioid safety. An Annual Perspective discussed the extent of harm associated with opioid prescribing and described promising practices to address opioid misuse.

Uncertainty in complex care situations is a common experience for both trainees and experienced practitioners. This review explores the concept of comfort with uncertainty in medicine and suggests that individual awareness of uncertainty is required to respond to the condition as it occurs. The authors advocate for educational and research strategies to further manage uncertainty in health care.