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Bubric KA, Biesbroek SL, Laberge JC, et al. Jt Comm J Qual Patient Saf. 2021;Epub May 24.
Unintentionally retained foreign objects (RFO) following surgery is a never event. In this study, researchers observed 36 surgical procedures to quantify and describe interruptions and distractions present during surgical counting. Interruptions (e.g., the surgeon or another nurse talking to the scrub nurse) and distractions (e.g., music, background noise) were common. Several suggestions to minimize interruptions and distractions during surgical counts are made.
Geerts JM, Kinnair D, Taheri P, et al. JAMA Netw Open. 2021;4(7):e2120295.
The COVID-19 pandemic has disrupted many aspects of health care delivery and has placed unprecedented pressure on health care workers. This consensus statement, based on input from an international panel of individuals with expertise in health leadership, health care, and public health, outlines 10 imperatives to guide health and public leaders during the post emergency stage of the pandemic. Imperatives addressed in the framework include supporting staff well-being and psychological health, preparing for future emergencies, managing the backlog of delayed care, and the importance of sustaining learning, innovations and collaborations that arose during the pandemic.

Andel SA, Tedone AM, Shen W, et al. J Adv Nurs. Epub 2021 Jul 10.

During the first weeks of the COVID-19 pandemic, 120 nurses were surveyed about nurse-to-patient staffing ratios, skill mix, and near misses in their hospitals. Personnel understaffing led to increased use of workarounds, and expertise understaffing led to increased cognitive failures, both of which shaped near misses. Hospital leaders should recognize both forms of understaffing when making staffing decisions, particularly during times of crisis.
Gabrysz-Forget F, Zahabi S, Young M, et al. J Surg Educ. 2021;Epub Apr 24.
An essential part of resident training is error recovery- recognizing an error has occurred and strategizing how to correct the error to maximize patient safety. Through interviews with surgical residents, barriers and facilitators to experience error recovery were supervision, self, surgical context, and situation safeness. Focusing on these factors may enhance residents’ ability to develop their error recovery skills.

ImproveDx. July 2021;8(4).

Adverse event reporting can clarify when mistakes happen and what reduction strategies to apply. This article describes existing efforts to examine diagnostic error through reporting and highlights tactics being employed.
Morrison AK, Gibson C, Higgins C, et al. Pediatr Qual Saf. 2021;6(4):e425.
Limited health literacy can lead to patients or caregivers misunderstanding care instructions. Researchers examined safety events occurring at one children’s hospital over a nine-month period and found that health literacy-related events accounted for 4% of all safety events. Health literacy-related events generally involved problems with medication (e.g., unclear discharge medication instructions, conflicting instructions), system processes (e.g.., failures to address language barriers), and discharge and transitions (e.g., unclear equipment information, unclear instructions about upcoming tests).
Chladek MS, Doughty C, Patel B, et al. BMJ Open Qual. 2021;10(3):e001254.
The I-PASS handoff bundle has been successful at improving patient safety during handoffs in the hospital. A pediatric emergency department implemented the I-PASS bundle to improve handoffs between medical residents. Results showed a 53% decrease in omissions of crucial information and residents perceived improvement in patient safety.
van Dael J, Gillespie A, Reader TW, et al. J Health Serv Res Policy. 2021;Epub Jul 7.
This retrospective study linked patient complaint data with staff incident reports to better understand the causes and severity of patient harm. Staff reported incidents with linked patient complaints frequently described greater harm from the safety incident and often noted adjacent safety events not reported by staff. The researchers explored linked events that generated contested patient and staff accounts, and how differing interpretations of the same incidents can support organizational learning.
Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y, et al. Obstet Gynecol. 2021;Epub Jul 9.
Patient misidentification errors can result in serious patient harm. The authors reviewed over 1.3 million electronic orders for inpatients at one New York hospital between 2016 and 2018 and found that wrong-patient order errors occurred more frequently on obstetric units than medical-surgical units. Medication errors were the largest source of order errors and commonly involved antibiotics and opioid and non-opioid analgesics.

Thomas Jefferson University, College of Population Health. Oct 1 - Dec 17, 2021.

Leaders have a distinct role in creating a culture that supports a high reliability organization(HRO). This virtual series will train senior acute care, long-term care, or skilled nursing facility staff to apply HRO concepts that support safe healthcare environments.
Adie K, Fois RA, McLachlan AJ, et al. Br J Clin Pharmacol. 2021;Epub May 23.
Medication errors are a common cause of patient harm. This study analyzed medication incident (MI) reports from thirty community pharmacies in Australia. Most errors occurred during the prescribing stage and were the result of interrelated causes such as poor communication and not following procedures/guidelines. Further research into these causes could reduce medication errors in the community.
Park J, Saha S, Chee B, et al. JAMA Netw Open. 2021;4(7):e2117052.
The patient-provider relationship plays an important role in the delivery of safe, quality health care.  Using electronic encounter notes, this qualitative study describes physician language used to express negative and positive attitudes toward the patient. While positive attitudes were generally expressed via explicit language (e.g., direct compliments), negative attitudes were not explicit and often expressed through questioning patient credibility, disapproval of patient reasoning or self-care, stereotyping, portraying the patient as difficult, and emphasizing physician authority over the patient.
Driessen RGH, Latten BGH, Bergmans DCJJ, et al. Virchows Arch. 2020;478(6):1173-1178.
Autopsies are an important tool for detecting misdiagnoses. Autopsies were performed on 32 septic individuals who died within 48 hours of admission to the intensive care unit. Of those, four patients were found to have class I missed major diagnosis. These results underscore the need to perform autopsies to improve diagnosis.
Wong CW, Tafuro J, Azam Z, et al. J Cardiac Failure. 2021;Epub May 25.
Misdiagnosis of cardiovascular conditions can lead to serious patient harm. This systematic review explored misdiagnosis of heart failure. Based on 10 included studies, the rate of heart failure misdiagnosis ranged from 16.1% (in an inpatient setting) to 68.5% (when general practitioners referred patients to specialists). Included studies found that heart failure is frequently misdiagnosed as chronic obstructive pulmonary disease (COPD).

Leitch S, Dovey S, Cunningham W, et al. BMJ Open. 2021;11(7):e048316.

In this retrospective study, researchers examined patient records to describe patient harm occurring in primary care settings in New Zealand. The majority of harms were minor; 4.5% of harms were considered severe. Nearly 82% of non-fatal harms were considered not preventable and generally arose from routine care.
Barbara L, Roberta DB, Vanda R, et al. J Patient Saf. 2021;Epub May 20.
Patient safety indicators can help hospitals identify and prevent potential adverse events. Researchers in this study developed a conceptual framework for monitoring patient safety and a set of fifteen actionable patient safety indicators.
Scott IA, Hubbard RE, Crock C, et al. Intern Med J. 2021;51(4):488-493.
Sound critical thinking skills can help clinicians avoid cognitive biases and diagnostic errors. This article describes three critical thinking skills essential to effective clinical care – clinical reasoning, evidence-informed decision-making, and systems thinking – and approaches to develop these skills during clinician training.