Understanding deviations in care can identify opportunities to improve care delivery and patient safety. This study assessed the incidence and nature of patient- and clinician-reported deviations from optimal care (“non-routine events” or NRE) during ambulatory surgery. The most common type of clinician-reported NRE was process deficiencies, while failures in communication between clinicians and patients or family members was the most common type of patient-reported NRE. Understanding patient perspectives on care deviations can identify opportunities for process improvements and more patient-centered care.

Missed diagnosis of aortic emergencies can result in patient death, therefore patients with presumed aortic syndromes may be transferred to aortic referral centers. Because interhospital transfers present their own risks, these researchers evaluated emergency transfers of patients who did not ultimately have a diagnosis of acute aortic dissection, intramural hematoma, penetrating aortic ulcer, thoracic aortic aneurysm, or aortic pseudoaneurysm. Approximately 11% of emergency transfers were misdiagnosed, secondary to imaging misinterpretation.

Health care–associated infections (HAIs) represent a significant source of preventable harm to patients. Targeted interventions have been shown to be effective in decreasing HAIs and events once deemed unavoidable, such as central line–associated bloodstream infections, are now considered preventable. In this systematic review and meta-analysis, investigators sought to determine the proportion of HAIs prevented by infection control efforts across countries of different income levels. From the 144 studies ultimately included in the analysis, they found that implementation of evidence-based interventions was associated with an overall reduction in HAIs and that there was no relationship to the financial status of the country in which the study was conducted. A past PSNet perspective discussed infection prevention and patient safety.

Simulation training has been increasingly employed in health care, largely due to its success in the aviation industry. Prior research suggests that simulation programs can lead to improved knowledge, skills, and behaviors among health care professionals. In this study, researchers video recorded 263 board-certified anesthesiologists performing two mannequin-based simulated emergencies to determine whether this type of simulation is a reliable way to evaluate competency. Blinded anesthesiologists then evaluated the recordings using standardized rating tools to assess the percentage of critical performance elements carried out and to provide an overall rating of participants' technical and nontechnical skills. In 284 of the simulated emergencies, the participating anesthesiologists completed 81% of the critical performance elements successfully. About 25% of the participants were given low overall ratings. The authors conclude that assessing anesthesiologists' skills in simulated medical emergencies can help identify opportunities for improvement and better inform continuing medical education initiatives. A past PSNet perspective discussed the literature on health care simulation.

Poorly designed systems can contribute to human error. This commentary discusses how applying human factors engineering principles to the care environment can enhance clinician behavior and reduce health care–associated infections.

… The Journal of hospital infection … J Hosp Infect … Mental models are psychological … representations of situations which affect an individual's expectations and courses of action taken. Illustrating how …

This systematic review of interventions to prevent health care–associated infections identified organizational factors such as positive safety culture, hospital-wide infection control efforts, guidelines, training, auditing, feedback, and optimal staffing and ergonomics. The results suggest that reducing hospital-acquired infections requires a systems approach.

Many studies have shown that patients admitted to the hospital on the weekend experience more preventable complications and are at increased risk for mortality. The mechanism for this finding is unknown and could be due to health care system factors (i.e., lower weekend staffing and availability of clinical services) or patient factors (i.e., those admitted on weekends could be more complex and at higher risk of death than weekday admissions). This population-based analysis from New South Wales, Australia sought to determine the contribution of health care system and patient factors to elevated weekend mortality by analyzing daily mortality rates for the 7-day period following weekend admission. For certain diagnoses, such as pulmonary embolism, the risk of death was elevated during the first 48 hours after weekend admission but declined thereafter, implying that health care system factors are the primary driver of the weekend effect. However, patients with cancer-related diagnoses continued to have elevated mortality risk for the full 7 days after weekend admission, implying that patient factors such as illness severity are the major contributor to excess mortality. Other diagnoses, such as stroke, showed a mixed pattern of system and patient factors. By providing a nuanced view of the types of diagnoses and factors associated with the weekend effect, this study demonstrates the need for tailored solutions for this well-documented problem.

… the International Society for Quality in Health Care … Int J Qual Health Care … Perceptions of safety culture in an …

This study discovered that task performance and mood were different on the night shift compared to daytime hours, a finding the authors attributed to fatigue. They advocate for restructuring of resident schedules to optimize rest in the setting of existing work hour restrictions.

This study describes the development of an open-ended survey tool administered to anesthesia providers at the conclusion of surgical cases, with the goal of contemporaneously identifying adverse events. The tool identified a broader array of adverse events and near misses than the traditional incident reporting system.

This study describes the practical aspects of designing, developing, and implementing a video methodology to observe patient care. The investigators outline their approach in capturing 270 operating room cases with lessons learned and suggestions for others interested in applying a similar approach for research and quality improvement activities. Discussion includes important technical considerations, processes for handling the captured video, and appropriate sensitivity and compliance with issues of human subject consent, provider privacy and confidentiality, and related medicolegal concerns. This video technique may provide a necessary mechanism to study the complex interplay of systems, individuals, and human factors, which represent a critical aspect of addressing patient safety improvements.

… experiences of other high-risk, error-prone industries. … Weinger MB; Englund CE. … MB … CE … Weinger … Englund … MB Weinger … CE Englund …