Classics and Emerging Classics

Improving opioid prescribing is a complex challenge that requires multipronged approaches to achieve safe patient pain management. This commentary offers insights to help organizations effectively implement the Centers for Disease Control and Prevention guideline and notes how misapplication of recommendations have resulted in unintended consequences such as patient harm.

Checklists have been shown to improve surgical safety in randomized controlled trials, but they have had varied impact when implemented in clinical practice. This interrupted time-series study examined surgical mortality before, during, and after implementation of the WHO surgical safety checklist. The rate of surgical mortality declined more during checklist introduction than it had before or after implementation, and hospital mortality did not decline among nonsurgical patients during the same time interval. The investigators, including checklist pioneer Atul Gawande, conclude that perioperative mortality has declined in association with checklist implementation. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

The unintended risks associated with integrating artificial intelligence (AI) systems into health care are a popular topic of debate. This commentary suggests that strong guidance is necessary to reduce risks while capitalizing on the potential inherent in AI to enhance decision-making, diagnosis, and risk management.

The second victim phenomenon refers to the emotional impact adverse events and patient harm can have on health care team members, including physicians and nurses. This meta-analysis sought to quantify psychological and psychosomatic symptoms experienced by second victims. Researchers identified 18 studies and found that embarrassment, guilt, regret, self-recrimination, anxiety, fear of future errors, reliving the incident, and difficulty sleeping were the most common symptoms. These results underscore how involvement in errors can have detrimental consequences for provider well-being. The authors recommend both preventive programs and postevent support for health care workers after medical errors. A PSNet interview with Albert Wu, who coined the term second victim, discussed approaches to address this safety issue.

This retrospective study of patients with a diagnosis of multiple sclerosis found that nearly 20% had been misdiagnosed and did not have the disease. The authors highlight the risks from misdiagnosis including exposure to high-risk medications with resultant adverse drug events and delay in correct treatment for patient conditions.

This mixed-methods study used direct observation and interviews to determine whether plan–do–study–act (PDSA) cycles were implemented as planned in a series of quality improvement efforts. The authors found that initial training efforts did not support PDSA implementation and that careful project selection, redesigned training, and hands-on support were all required to support frontline teams in using the PDSA method.

Team development is an important focus of safety improvement. This article provides an overview of team training science and highlights aviation, military, and health care failures that motivated research to understand the psychology of teams. The authors emphasize the importance of multidisciplinary collaboration and the contributions of psychologists as research partners in this work.

Care transitions represent a vulnerable time for patients, especially at the time of hospital discharge. In this systematic review, researchers identified several factors related to discharge summaries that may adversely impact the safety of discharged patients, including delays in sending discharge summaries to outpatient providers as well as missing or low-quality information.

Health care leaders have embraced applying safety sciences methods to improve care delivery. This review discusses the evolution of health care safety from focusing on reactive analysis and response to error (Safety-1) to one that seeks to prevent errors through emphasizing safe system design (Safety-2). The authors advocate for developing a resilient system to examine what works well and incorporate those practices into daily work.

Root cause analysis is a widely used patient safety and quality improvement process for investigating adverse events. This book includes detailed steps to identify system-level causes including how to use diagrams and figures to assist in brainstorming causes and potential solutions.

The term "second victim," coined by Dr. Albert Wu, has engendered mixed responses from patients and health care professionals. This commentary raises concerns that the term negates the sense of responsibility for errors that result in harm and advocates for abandoning it.

Machine learning in health care is in the early stage of application. This review explores machine learning and its potential to enhance clinical decision-making as a tool for safe value-based care. The authors discuss how machine learning can affect prognosis, diagnosis, treatment, clinician workflow, and access to expertise. They describe key challenges to integrating machine learning in health care, including access to high-quality data.

Misinterpretations of critical tests can lead to diagnostic delays and patient harm. This review suggests combining computerized and human analysis of electrocardiogram results to enhance test interpretation accuracy and effectiveness.

This editorial discusses how structural racism contributes to health inequities between blacks and whites in the United States, with an emphasis on cancer care. The authors propose three strategies for addressing structural racism in healthcare: (1) clinicians can make the invisible visible by examining disparities in their practices and exploring disparities in patient-level quality measures; (2) health care organizations can engage the community in an effort to change the accepted explanatory narrative, from one about biology or behavior to a story of a pathological social system that can be improved, and; (3) institutions can make systemic changes to eliminate structural racism by engaging in quality improvement efforts, educating healthcare workers, updating technical skills, and using patient navigators to connect patients to necessary services.

Transitions of care, whether from the hospital to the outpatient setting or within the hospital itself, represent a vulnerable time for patients. Inadequate communication during handoffs that occur as part of care transitions can contribute to adverse events and errors, including medication errors. This study of 58 intensive care units (ICUs) across 34 United States hospitals and 2 Dutch hospitals sought to assess medication errors among patients transferred from ICUs. Of the 985 patients included in the study, almost half (46%) experienced a medication error during transition out of the ICU. Discontinuing orders and reordering medications at the time of transfer out of the ICU as well as daily patient rounding in the ICU were associated with decreased odds of medication error during transition. A past Annual Perspective discussed challenges associated with handoffs and transitions of care.

Artificial intelligence (AI) may have the capacity to improve diagnosis. Researchers found that an AI system was able to detect breast cancer using mammography with accuracy similar to that of the average of the 101 radiologists whose interpretations were included in the study.

Using clinical vignettes, investigators conducted semi-structured interviews with those prescribing medications in a pediatric intensive care unit to better understand human factors contributing to prescribing errors. They found that cognitive load was the main contributor to such errors.

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 systematic review examined whether mobile technology has been shown to improve teamwork or communication in acute care settings. Few studies met methodological quality standards, but researchers conclude that mobile technology holds promise to enhance safety through improved teamwork and communication in hospital settings.

Wrong-patient errors in blood transfusion can lead to serious patient harm. Research has shown that use of barcodes to ensure correct patient identification can reduce medication errors, but less is known about barcoding in transfusion management. This pre–post study examined the impact of barcode labeling on the rate of wrong blood in tube errors. Investigators found that use of barcoding improved the accuracy of labels on blood samples and samples that had even minor labeling errors had an increased chance of misidentifying the patient. The authors conclude that the results support the use of barcoding and the exclusion of blood samples with even minor labeling errors in order to ensure safe blood transfusion. An accompanying editorial delineates the complex workflow, hardware, and software required to implement barcoding for transfusion. A past WebM&M commentary discussed an incident involving a mislabeled blood specimen.