Usability concerns continue to affect the safe use of electronic health information systems. This commentary describes the role of vendors in improving usability, how regular testing can ensure safety, and the impact of organizational culture on the safe use of information technology over time.

Retained surgical items (RSIs) can lead to serious patient harm. Survey findings from 21 clinicians and stakeholders in Switzerland emphasized the importance of addressing production pressures, encouraging a culture of safety and teamwork, and implementation of effective counting procedures to reduce the incidence of retained surgical items.

Surgical site infections (SSI) are a common, but preventable, complication following surgery. This study sought to determine the association of commitment to, knowledge of, and social norms surrounding SSI prevention efforts and safety climate strength and level. Based on responses from nearly 2,800 operating room personnel in Sweden, only commitment and social norms were associated with safety climate level. None were associated with safety climate strength.

Anesthesia medications prepared in the operating room are vulnerable to errors at all stages of medication administration, including preparation and dilution. In this study, anesthesiologists were asked to prepare the mixture of three drugs used for spinal anesthesia for cesarean section. Results show deviation from the expected concentration and variability between providers. The authors recommend all medications be prepared in the hospital pharmacy or purchased pre-mixed from the manufacturer to prevent these errors. 

Effective patient safety improvement efforts address safety threats at the individual, interpersonal, and organizational levels. This study characterizes safety measures described in incident reports from German outpatient care settings. Of the 243 preventative measures identified across 160 reports, 83% of preventative measures were classified by the research team as “weak,” meaning that they focus on influencing human behavior rather than on treating underlying problems (e.g., alerts, trainings, double checks).

Historically, there have been many patient safety errors associated with healthcare workers’ failure to speak up and report when they notice a problem. Many studies have identified organizational culture as important in creating a safe environment for workers to report medical errors. This study reports on a multimodal program to educate and train healthcare workers resulting in improvements on speaking up behaviors.

The World Health Organization (WHO) surgical safety checklist (SSC) can improve perioperative outcomes but implementation challenges persist. This study found that peer observation and immediate peer feedback improved SSC compliance and identified primary areas for future efforts to further improve compliance (i.e., reducing interruptions and improving sign outs).

… reactions from involved individuals. … Niederhauser A, Schwappach DLB. Speaking up or remaining silent about patient …

During the first surge of the COVID-19 pandemic, a rapid redeployment of noncritical care healthcare staff was necessary to meet the unprecedented number of patients needing critical care. A New York health system developed a multidisciplinary simulation training program to prepare the redeployed staff for new roles in the intensive care unit (ICU). The training included courses on management of a patient with acute decompensation with COVID-19, critical care basics for the non-ICU provider, and manual proning of a mechanically ventilated patient.

Polypharmacy and potentially inappropriate medications continue to pose health risks in older adults. Using a Delphi approach, experts identified 85 minimal requirements for safe medication prescribing in nursing homes. The five key topics recommend structured, regular review and monitoring, interprofessional collaboration, and involving the resident.

… of surgical safety checklists.  … Fridrich A,  Imhof A, Schwappach DLB. How much and what local adaptation is …

This study examined patient safety issues stemming from health information technology (HIT)-related information management hazards. The authors identified eleven thematic groups describing such hazards occurring at a systemic level, such as fragmentation of patient information, “information islands” (e.g., nurses and physicians have separate information sets despite the same HIT system), and inadequate information structures (e.g., no drug interaction warning integrated in the chemotherapy prescribing tool).

Double checking is one strategy for detecting and preventing medication errors; however, its effectiveness is unclear. This editorial presents a framework intended to further research and clinical practice by defining and classifying checking procedures and differentiating them from other medication-related safety behaviors.

This study focused on healthcare workers speaking-up behavior in six psychiatric hospitals in Switzerland. The authors found significant differences in speaking-up despite having moderate to high scores on items that were associated with psychological safety. Although nurses reported patient safety concerns more frequently, they also remained silent more often compared with psychologists and physicians, indicating they may feel less psychological safety.

Disruptive and unprofessional behavior in health care can compromise safety culture. Prior research has shown that male physicians and those working in procedural specialties may be more likely to demonstrate unprofessional behavior. Experiencing such incivility may have important implications on the clinical performance of those impacted. In this multicenter, prospective, randomized controlled trial, researchers subjected anesthesiology residents to a simulated operating room emergency in either a normal or a disrespectful environment; blinded evaluators rated their performance. They found that residents exposed to rude environments scored lower on every performance measure, although there was minimal difference in the self-assessment scores between the two groups. The authors suggest that improving the culture in operating room environments is crucial and advocate for focused education on communication in stressful situations during medical training. A past WebM&M commentary discussed an incident involving a communication failure in a pediatric intensive care unit.

Prior research has shown that including errors in training may result in improved retention of knowledge and skills. In this study, first-year anesthesia residents participated in a simulation involving hyperkalemia management. Half received support from an attending physician while the other half participated in the scenario independently. The groups were further split so that half of those practicing independently and half of those working with an attending experienced simulated mortality of the patient. The residents participated in another hyperkalemia simulation 6 months later without attending assistance. Residents who had practiced independently and experienced simulated mortality in the initial hyperkalemia scenario achieved the lowest mortality rate compared to the other groups during the follow-up simulation activity.

This synthesis of 19 qualitative studies of the second victim phenomenon, or the effects of an adverse outcome or error on clinicians, establishes a framework to characterize second victim experiences. The authors recommend including second victim perspectives into root cause analyses in order to improve safety culture.

Human factors perspectives can inform design and implementation of safety interventions in health care. This commentary summarizes the role of human factors engineering and checklists as safety improvement strategies in plastic surgery. The authors highlight nontechnical skill development, checklist customization, raising of concerns, and safety assessment as key areas of focus for the specialty.

This survey study presented physicians and nurses with four scenarios involving error and rule violations and found wide variation in their reported likelihood of voicing safety concerns. This emphasizes the need to bolster safety culture such that health care workers feel empowered to speak up to identify and mitigate errors.

Although doctors and nurses in an oncology unit all agreed on the importance of speaking up in unsafe situations, they described various barriers to actually doing so, including the potential to damage relationships and concern about the accuracy of their own assessment of the situation.