… at least one AE, most of which were preventable. … Plint AC, Newton AS, Stang A, et al. How safe are paediatric emergency …

The emergency department (ED) is a complex and high-risk environment. In this study, patient deaths occurring within 7 days of ED discharge were analyzed to determine if the deaths were anticipated or unanticipated and/or due to medical error. Rates of unanticipated death due to medical error were low, however clinicians should consider related patient, provider, and system factors.

… guidelines and strengthening dual diagnosis detection. … Calder LA, Perry J, Yan JW, et al. Adverse events among emergency department patients with cardiovascular conditions: a multicenter study. Ann Emerg Med. Epub 2021 Feb 23. …

This commentary reviews the principles of high reliability organizations and their application to emergency department pandemic response and describes the experience of one children’s hospital in Alberta, Canada applying these principles in responding to the COVID-19 pandemic. Actions taken by the hospital included the use of an interprofessional ED quality council to identify processes where high reliability is essential in the context of the COVID-19 pandemic, such as resuscitations, intubations, donning and doffing of personal protective equipment (PPE), and preventing contamination.

This article describes emergency department (ED)-related adverse events in pediatric patients presenting to the ED at a pediatric hospital in Canada over a one-year period.  Among 1,319 patients at 3-months follow-up, 33 patients (2.5%) reported an adverse event related to their ED care.  The majority of these events (88%) were preventable. Most of the events involved diagnostic (45.5%) or management issues (51.5%) and resulted in symptoms lasting more than one day (72.7%).

Root cause analysis (RCA) is a vital tool to assess errors and prevent their recurrence. However, many have identified limitations to traditional RCAs. This study found that when RCA was adapted into a simulation format and compared to traditional RCA, simulation participants identified novel sources of error as well as creative solutions.

Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. This commentary describes the importance of standardization, checklist use, auditing and feedback, peer coaching, and interdisciplinary communication as strategies to reduce risks. The discussion spotlights the need for national guidelines and definitions to reduce variation in auditing and training activities and calls for heightened engagement of health care professionals to improve the safety and quality of obstetric care in Canada. An Annual Perspective reviewed work on improving maternal safety.

… the major barrier for paramedics in voluntarily reporting a patient safety event in the prehospital setting . The …

… of the American Society for Healthcare Risk Management … J Healthc Risk Manag … Human factors and patient safety … causes of medical care failure. This commentary describes a framework that applies elements of system safety , …

This scoping review of cognitive support technology in the emergency department found that physician use of point-of-care support was the most widely studied. Researchers found that few studies measured actual use of cognitive support. The limited data suggest that real-world use of cognitive support delivered via technology remains low.

Children are vulnerable to errors in various health care settings. This review identified thematic factors that uniquely affect the safety of pediatric patients such as physiological development and dependency on adults for care. Safety interventions included training programs and monitoring adverse events. Medication errors were the main patient safety concern identified in the literature.

Procedural sedation is more commonly used among pediatric patients compared to adult patients. In this prospective study across six emergency departments, researchers found that the occurrence of serious adverse events among children receiving sedation varied depending on the type of medication used.

Morbidity and mortality conferences are a longstanding patient safety activity. This pre–post study assessed the impact of implementing a structured method to enhance morbidity and mortality rounds. Investigators found that discussion of cognitive biases and systems issues increased following the intervention, and they recommend wider dissemination of their morbidity and mortality rounds model.

… & safety … BMJ Qual Saf … Inpatient mortality represents a key outcome measure in health care quality and safety. This …

… The authors suggest that this utilization pattern may be a promising trigger tool to identify adverse events. …

… outcomes remains controversial . This study reported a reduced time to treatment for patients in shock, and a resulting decrease in mortality, after implementation of a hospital-wide RRS. Investigators compared outcomes 2.5 …

This qualitative systematic literature review identifies and summarizes evidence for the use of potassium-containing products in hospitals. Results include examination of current recommendations and data that address those consensus-driven guidelines. Discussion shares the limitations of the literature about medication safety practices and calls for greater attention to improving the evidence base behind patient safety practices in general. The authors conclude that inadequate evidence exists to support specific best practices for the proper handling of potassium products.