Classics and Emerging Classics

Disclosure of errors and adverse events is increasingly encouraged in health care. This article reviews disclosure and resolution pathways and discusses barriers to pathway implementation.  Ensuring clinicians are equipped with tools to implement effective disclosure and fair resolution benefits both patient safety and clinician emotional well-being.

Staff willingness to report threats to patient safety is critical to preventing errors and improving safety and is an indicator of an organization’s safety culture. The authors discuss studies exploring what factors influence whistleblowing, organizational responses, and implications for practice or policy. The authors concluded that the existing literature focuses on the decision to speak up. There is limited evidence discussing organizational responses or systems-level changes, yet these actions influence whether the patient safety threats are addressed and if future events will be reported.

Cascades of care (or follow up) on incidental findings from diagnostic tests are common but are not always clinically meaningful. This study reports the results of a nationally representative group of physicians who were surveyed on their experiences with cascades. Almost all respondents had experienced cascades and many reported harms to patients and personal frustration and anxiety that may contribute to physician burnout.

Clinician burnout is a known contributor to unsafe care. This report summarizes evidence on the causes and impacts of clinician burnout. The authors share six recommendations for improvement which include redesign of the learning environment, technologies, and support services for clinicians.

Patients and families are critical partners in identifying and preventing patient safety events. A systematic review found willingness among patients and families engage in safety activities, but barriers such as limited patient/family knowledge, poor communication, and lack of systems-level efforts supporting patient and family engagement may hinder effective engagement.

New meta-analysis on potential impacts of provider burnout concludes a relationship exists between high levels of burnout—from factors such as high workload and ineffective interpersonal relationships—and worsening patient safety.

Staff workload and stress can impact patient safety and increase the risk of an adverse event. A survey of hospital nurses in Iran found that job demands (“role stressors”) and stressors stemming from interpersonal relations were significant predictors of adverse events.

Simulation is an active learning methodology being used in hospitals to improve patient care.  Results of this systematic review that focused on acute care nurse simulation training and patient safety outcomes indicate that simulation training can be effective for improving patient safety outcomes in this context; the authors note, however, that additional high–quality research is needed to support this field.

Medical overuse has been described as a patient safety problem among both adult and pediatric patients. Consistent with prior research, this review suggests that overtesting and overtreatment are common and have the potential to cause harm to patients.

Prior research has shown that nurse staffing is an important consideration with regard to patient safety. Lower nurse-to-patient ratios are associated with increased mortality and have prompted policies mandating particular nurse staffing ratios, especially in the intensive care unit. To address the criticism that previous studies have compared different institutions with higher nurse staffing to those with lower staffing levels and that there may be other reasons for observed differences in patient outcomes, this study evaluated the relationship between inpatient mortality and exposure to shifts with decreased registered nurse staffing, lower nursing support staffing, and increased patient turnover at three sites within a single academic medical center. Consistent with prior studies, researchers found an association between low nurse and nursing support staffing and increased patient mortality; there was no association between patient turnover and mortality. An accompanying editorial advocates for additional prospective research on interventions put in place to address nurse staffing.

This survey of 282 primary care physicians and ambulatory specialists found that several electronic health record design features contributed to clinician burnout, including excessive data entry requirements and long copied-and-pasted notes. However, other work environment factors (such as clinician workload) were more strongly predictive of work stress and burnout.

Burnout has been linked to medical errors in a variety of clinician environments. This commentary describes burnout as an occupational problem in health care and recommends assessment at the departmental level to achieve lasting change.

Surgeon technical skill, real-time problem solving, and communication quality are essential for avoiding harm during surgery. This study found that those types of human errors were responsible for 51.6% of 188 surgical adverse events at 3 hospitals. A past PSNet perspective delineates the evolution of surgical patient safety.

Physician burnout and depression are prevalent, costly, and likely to worsen the existing physician shortage. Physicians with depression and burnout also report committing more errors than their peers. Investigators prospectively examined whether pediatric residents reporting depression or burnout were involved in more errors. Participants experiencing depression committed three times as many harmful errors as those without depression. Residents with burnout did not commit more errors or more harmful errors. A strength of this study is that the errors were assessed objectively rather than by self-report. The direction of causality remains unclear—whether physicians with depression commit more harm or committing harm leads to depression. A past PSNet interview discussed how to promote physician satisfaction and well-being.

Clinicians may experience distress after being involved in adverse events. This study of 4369 Dutch providers examined the prevalence and duration of clinicians' symptoms associated with involvement in an adverse event as well as the relationship between the degree of harm and symptom duration. As expected, clinicians reported symptoms such as hypervigilance, self-doubt, and discomfort following adverse events. These symptoms were more severe and long lasting for events with more serious harm to patients, compared to events with less severe harm. The authors call for organizations to provide support for clinicians involved in adverse events. A previous PSNet perspective discussed efforts to ameliorate the impact of errors on providers.

The extent of harm due to patient safety problems varies across studies. This systematic review sought to estimate the prevalence of preventable harm in medical care overall. Researchers synthesized data from 70 studies and estimated that 6% of patients receiving medical care experience preventable harm. Harm related to medications, diagnosis, health care–associated infections, and procedures accounted for significant proportions of preventable harm. The authors conclude that focusing on evidenced-based strategies to address preventable patient harm would improve health care quality and subsequently reduce costs. A related editorial calls for improving measurement of preventable harm. Another editorial spotlights the importance of understanding the causes of preventable harm in health care.

This systematic review examined the override rates of several different clinical decision support approaches. Researchers conclude that role tailoring—the provision of different alerts to prescribers versus pharmacists—was the most successful method to reduce alert fatigue. They recommend redesigning decision support to reduce alert fatigue.

Reducing opioid prescribing in pain management is a key strategy to address the opioid crisis. This review highlights the unique role of the anesthesiologist in this approach. The authors emphasize preoperative identification of patients at risk for long-term opioid use and suggest organizational, clinical, and research strategies that can be led by anesthesiologists to reduce opioid use.

Many older patients experience medication-related harm due to inappropriate prescribing. This meta-analysis found that potentially inappropriate medication prescribing in older patients worsened health-related quality of life and increased emergency department visits and hospitalizations. A WebM&M commentary discussed strategies for safer medication management for older patients.

Diagnostic errors are widely acknowledged as a common patient safety problem, but difficulty in measuring these errors has made it challenging to quantify their impact. This study utilized a large national database of closed malpractice claims to estimate the frequency and severity of diagnostic errors. Researchers also sought to determine the types of diagnoses most vulnerable to misdiagnosis. Missed or delayed diagnoses accounted for 21% of 55,377 claims analyzed, and the majority of these cases resulted in permanent disability or death. These findings corroborate earlier research on closed malpractice claims in primary care and emergency department settings. Investigators found that three groups of diagnoses accounted for the majority of closed claims and high-severity events: vascular events (such as myocardial infarction and stroke), infections (such as sepsis), and cancer. This study represents an important step forward in identifying areas for improvement in diagnosis, but caution should be exercised in extrapolating these results, since malpractice claims only account for a small proportion of all adverse events experienced by patients. A previous PSNet perspective discussed momentum in the field of diagnostic error over the past several years.