Classics and Emerging Classics

This systematic review examined nature of workplace team resilience, how it is defined, the individual factors associated with team resilience, and the relationship between individual- and team-level resilience. The results of the review informed the development of a theoretical framework conceptualizing team resilience and integrating different conceptual components of team resilience.

This review summarizes studies of training programs targeting healthcare professionals’ speaking up skills. The authors found that most training programs were limited to a one-time training delivered to a single profession (i.e., limited to doctors or nurses).  The majority of programs addressed legitimate power (i.e., social norms such as titles) but few addressed other types of power (e.g., reward or coercive power, personal resources) or the non-verbal (i.e., emotional) skills required in speaking-up behaviors.  

This commentary discusses the ongoing impact of COVID-19 on the physical, emotional, and mental health on the healthcare workforce and outlines five high-priority actions at the organizational- and national level to protect the health and wellbeing of the healthcare workforce during and after the pandemic.  

This Cochrane review evaluated the differential impacts of personal protective equipment (PPE) types and methods of donning/doffing on contamination and infection risk for healthcare workers. The authors included 24 studies (14 randomized controlled trials) representing over 2,200 patients. The authors found that PPE covering more body surface area may lead to better protection but at the cost of more difficult donning or doffing – for example, a powered, air-purifier respirator may protect against contamination better than a N95 mask and gown but with less compliance with donning. PPE design modifications may decrease the risk of contamination compared to standard PPE (e.g. better fit around neck, wrists and hands). Certain donning and doffing procedures, such as following CDC doffing guidance, may reduce contamination and increase compliance. The authors note that simulation studies exploring which combinations of PPE and specific donning/doffing procedures protect best against contamination are warranted.

This study assessed the impact of combined use of two surgical safety checklists on morbidity, mortality, and length of stay – the Surgical Patient Safety System (SURPASS) is used to address preoperative and postoperative care, and the World Health Organization surgical safety checklist (WHO SSC) is used for perioperative care.  In addition to existing use of the WHO SSC, the SURPASS checklist was implemented in three surgical departments in one tertiary hospital in Norway. Results demonstrated that combined use of these checklists was associated with reduced complications reoperations, and readmissions, but combined use did not impact mortality or length of stay.

Using clinical artificial intelligence as an example, these authors posit that digital tools are challenging standard clinical practices around assigning blame and assuring patient safety. They discuss moral accountability for harm to patients and safety assurances to protect patients against such harm, and examine these issues from both a clinician and patient perspective.

The authors present a nomenclature to describe eight types of diagnostic errors anticipated in the COVID-19 pandemic (classic, anomalous, anchor, secondary, acute collateral, chronic collateral, strain and unintended diagnostic errors) and highlight mitigation strategies to reduce potentially preventable harm, including the use of electronic decision support, communication tactics such as visual aids, and huddles. Organizational strategies (e.g., peer-support, duty hour limits, and forums for transparent communication) and state/federal guidance around testing and monitoring diagnostic performance are also discussed.

Potentially inappropriate prescribing in older adults can lead to adverse health outcomes and worsened health-related quality of life. This meta-analysis estimated the prevalence of potentially inappropriate prescribing in older adults to be 3.3%, and estimated that potentially inappropriate prescribing explains 7.7 to 17.3% of adverse outcomes affecting older adults in primary care. Interventions to prevent potentially inappropriate prescribing should be prioritized as a key strategy to reduce medication-related harm along older adults in primary care settings.

This meta-analysis examined the psychological effects of viral outbreaks on clinicians and effective strategies to manage stress and psychological distress. The review included 59 studies involving severe acute respiratory syndrome (SARS), COVID-19, Middle East respiratory syndrome (MERS), Ebola and influence. Compared with clinicians at lower risk, those in contact with affected patients had greater levels of both acute and post-traumatic stress, as well as psychological distress. Clinicians were at increased risk for psychological distress if they were younger, more junior, had dependent children, or had an infected family member. Identified interventions to mitigate stress and psychological distress included clear communication, infectious disease training and education, enforcement of infection control procedures, adequate supply of personal protective equipment (PPE) and access to psychological support.

This systematic review analyzed 36 articles exploring factors enabling psychological safety in healthcare teams. The review identified five themes of enabling factors: (1) priority for patient safety, such as safety culture or leadership behavior; (2) improvement or learning orientation leading to a culture of continuous improvement or change-oriented leadership; (3) support from peers, leadership or the organization; (4) familiarity between and across teams and with team leaders, and; (5) status, hierarchy and inclusivity. These themes can aid future objective measures of psychological safety and interventions to improve psychological safety within teams. 

This systematic review assessed randomized and non-randomized trials comparing the performance of artificial intelligence (AI; specifically deep learning algorithms) in medical imaging versus expert clinicians in order to characterize the state of the evidence and suggest future research directions which encourage innovation while protecting patients. The review identified 10 registered trials and 81 published non-randomized trials. Although 61 of 81 published studies reported that AI performance was comparable or better than that of clinicians, the authors identified few prospective studies or studies conducted in real-world settings; additionally, overall risk of bias was high and adherence to reporting standards was poor. Future studies examining the impact of AI in medicine must decrease risk of bias, increase relevance to real world clinical settings, and improve reporting and transparency.

To support the needs of healthcare workers during the COVID-19 pandemic, this rapid evidence review of qualitative research studies sought to identify barriers and facilitators to healthcare workers adherence to infection prevention and control guidelines for respiratory infectious diseases. The authors included 20 studies in their analysis; these studies explored the views and experiences of nurses, doctors and other healthcare workers working in hospitals, primary care, and community care settings dealing with infectious diseases such as SARS, H1N1, MERS, TB, or seasonal influenza. Identified barriers included local guidelines that were lengthy, ambiguous or not reflective of national or international continuously changing guidelines, lack of support from management to adhere to guidelines, and lack of high-quality personal protective equipment (PPE). Facilitators to guideline adherence included clear communication and training about the infection and use of PPE, sufficient space to isolate patients, workplace safety culture, and perceived value of adhering to infection prevention and control guidelines.

Huddles are one technique to enhance team communication, identify safety concerns and built a culture of safety. This systematic review synthesized 24 studies examining the impact of either unit-based or hospital-wide/multiunit safety huddles. The majority of studies were uncontrolled pre-post study designs; only two studies were controlled and quantitatively measured intervention adoption and fidelity. Results for unit-based huddle programs appear positive. Given the limited number of studies evaluating hospital-wide huddle programs, the authors conclude that there is insufficient evidence to assess the benefit. Further research employing strong methodological designs is required to definitively assess the impact of huddle programs.

In this systematic review, the authors pooled over 80,000 patients and 760 harmful diagnostic errors from 22 studies and estimated the prevalence of harmful diagnostic errors among hospitalized patients to be 0.7% (95% CI, 0.5-1.1%). Fourteen common diagnoses account for more than half of all missed or delayed diagnoses, with the most frequent being cancer (11%) and pulmonary embolism (9.6%). Extrapolated to the United States, these estimates correspond to approximately 249,900 harmful diagnostic errors each year.

This retrospective mixed-methods study explored patient safety within a pediatric telemedicine triage service by assessing the appropriateness and reasonableness of the diagnosis reached by the online physician. The researchers analyzed a random sample of telephone consultations and conducted qualitative interviews with physicians to obtain their perspectives about factors impacting their reaching diagnosis and deciding on reasonable and appropriate treatment. Analysis of telephone consultations found high levels of diagnosis appropriateness, decision reasonableness and accuracy. Physician interviews revealed six themes for appropriate diagnosis and decision-making: (1) use of intuition, (2) experience, (3) use of rules of thumb and protocols, (4) making shared decisions with parents, (5) considering non-medical factors, and (6) using additional tools such as video chat or digital photos when necessary.

This commentary discusses the provision of safe care in long-term care settings during the COVID-19 pandemic. The authors propose the following measures to ensure the safety of long-term care patients: facilities should only accept patients with COVID-19 infections if they can provide effective airborne isolation; patients recovering from COVID-19 need to have 2 negative tests on 2 consecutive days, as well as remain fever-free without mediation for at least 48 hours and not require ventilatory support that generates aerosols; facilities should screen potential admissions for typical and atypical signs and symptoms of COVID-19, and; facilities that are currently COVID-19 naïve should not accept any new admissions for whom there may be a concern for COVID-19.

The authors describe eight empirical recommendations for optimizing infection control and operating room (OR) management during the COVID-19 pandemic. Recommendations address (1) hand hygiene, (2) environmental cleaning, (3) patient decolonization, (4) vascular care, (5) surveillance of pathogen transmission, (6) efficient use of personal protective equipment (7) OR scheduling, and (8) postoperative recovery settings.

To address the negative psychological impacts faced by healthcare workers during the COVID-19 crisis, the authors of this commentary recommend three strategic principles for healthcare institutions responding to the pandemic: Encourage leadership to focus on resilience  Ensure that crisis communication provides both information and empowerment Create a continuum of staff support within the organization to address a surge in mental health concerns among healthcare workers.

This issue brief discusses a sociotechnical approach to understanding safe diagnosis and the range of data sources required for the follow-up and tracking of diagnostic information. The publication recommends a strategy to support health care organizations in identifying and beginning to measure diagnostic error to enable learning. This issue brief is the first in a series on diagnostic safety.

This article provides a critical review of the literature about moral injury observed in nurses after a patient safety incident. The authors describe ‘moral injury’ as an experience violating deeply held moral values and beliefs, which can place and individual at risk for burnout and post-traumatic stress disorder. Moral injury symptoms identified in this review included guilt, shame, spiritual-existential crisis, and loss of trust. The authors posit that moral injury may be a more appropriate term for what has been historically referred to as the ‘second victim’ phenomenon.