Inappropriate care, such as under- or over-treatment or unnecessary hospitalizations, can place patients at risk for adverse events. This observational study set in a high-complexity hospital in Spain found that patients with inappropriate hospital admissions (IHA) have a higher risk of subsequent adverse events, contributing to longer stays and additional costs.

Fatigue and sleep deprivation of anesthesia providers can result in decreased non-technical skills and psychomotor functioning. This study of 1,200 anesthesia and intensive care trainees in Europe describes the impact of work-related fatigue on well-being, commuting, and potential for medical errors. Two-thirds of respondents reported making or nearly making a medical error after working long hours. In addition to implementing shorter work schedules, the authors also encourage a culture where it is acceptable to admit fatigue, and where resting is encouraged.

… good or very good. Of patients who viewed both, there was a slight, though not statistically significant, preference for the oral presentation. … Bannsgard M,  Nouri A, Finizia C, et al. Communicating patient safety information through …

The COVID-19 pandemic dramatically impacted healthcare delivery and raised concerns about exacerbating existing patient safety challenges. Based on incident reporting data from three large US academic medical centers from January 2020 through December 2021, researchers found that patient safety event rates did not increase during the COVID-19 pandemic, but they did observe a relationship between staffing levels during the pandemic and patient safety event rates.

Organizational pressures sometimes lead to redeployment or task reallocation such as shifting infusion tasks from specialty nurse teams to generalist nurses. This survey of nurses in the United States found that infusion task reallocation led to increased job demands and reduced resources, thereby contributing to lower perceived organizational safety.

Research into the impact of racism on health outcomes has increased in recent years, but there has been less emphasis on ageism or the intersection of ageism and racism. This commentary highlights the ways racism (e.g., clinical algorithms), ageism (e.g., proposed measures to ration care) and the intersection of the two (increased morbidity and mortality of COVID-19 on older people of color) impacts health outcomes. Recommendations for current clinicians and health profession educators are provided.

Simulation is becoming more common in healthcare education programs, but often focuses on in-hospital, skills-based training aimed at developing team human factors skills. This systematic review included 72 studies from 2004-2021 that included human factors skills with a variety of different designs, types of training interventions, and assessment tools and methods. The authors concluded that simulation-based training was effective in training teams in human factors skills; additional work is needed on the retention and transfer of those skills to practice.

The AHRQ Patient Safety Indicators (PSI) capture the quality and safety in inpatient care and identify potential complications. This study compares the incidence of PSI-12 (perioperative venous thromboembolism (VTE)) in patients with and without acute COVID-19 infection. Patients with acute COVID-19 infection were at increased risk for meeting the criteria for PSI-12, despite receiving appropriate care. The researchers suggest taking this into consideration and updating PSIs, as appropriate.

… discrepancy data from four long-term care facilities over a 9-month period and found that nearly 41% of newly admitted … more medications and those with certain comorbidities (e.g., heart failure, anemia, hypertension) were at greatest … conditions or pain. … Patterson ME,  Bollinger S, Coleman C, et al. Medication discrepancy rates and sources upon …

… Saf. … Identifying and reducing diagnostic errors remains a critical patient safety concern. This prospective study asked clinicians if they perceived that a diagnostic … acute care patients experienced diagnostic errors. … Huang C, Barwise A, Soleimani J, et al. Bedside clinicians' …

… of retrospectively detecting adverse events. In this study, researchers used data from 31 Spanish hospitals to validate a trigger tool in general and gastrointestinal surgery … Zapata AH,  Rodríguez Cuéllar E, de la Fuente Bartolomé M, et al. Predictive power of the "trigger tool" for the …

Misdiagnosis in the emergency department (ED) can result in increased morbidity and mortality. This retrospective chart review of patients admitted from the ED to hospital explored the concordance of ED admission and hospital discharge diagnoses. Results show 21.77% of patients had discordant diagnoses; discordant diagnosis was associated with increased length of stay, mortality, and up-triage to ICU.

Technical and procedural skills are an important emphasis of medical training. This article briefly summarizes the “as low as reasonably achievable” (ALARA) approach, which was developed for the nuclear industry and has been used in radiology. The authors outline how ALARA risk standards can be adapted by training program directors to measure procedural competency and assess and reduce bedside procedural risks.

The COVID-19 pandemic has resulted in concerns about psychological and emotional well-being of health care professionals. In this cross-sectional study, critical care and emergency nurses in Spain report fears of COVID-19 infection, elevated workloads, higher nurse-to-patient ratios, communication struggles with management, and socio-emotional challenges in caring for their patients and themselves during the pandemic.

This systematic review identified five articles exploring factors influencing error disclosure and reporting practices by nurses in residential long-term care settings. Nurses were not always willing to disclose errors due to lack of confidence, knowledge and understanding of error disclosure guidance, as well as fear of repercussions, litigation, and loss of trust. Nurse leaders were identified as playing an important role in how incident reports are processed and used for improving safety, and should encourage and support error disclosure.

… survey data from the American Hospital Association, this study analyzed the association between hospitals’ nursing … but higher catheter-associated urinary tract infection and surgical site infection scores. The authors conclude that … seem to improve nursing-sensitive patient safety outcomes, there are still opportunities for improvement. …

This study analyzed malpractice claims to characterize nursing involvement in diagnosis-related (n=139) and failure-to-monitor malpractice (n=647) claims. The most common contributing factors included inadequate communication among providers (55%), failure to respond (41%), and documentation failures (28%). Both diagnosis-related and physiologic monitoring cases listing communication failures among providers as a contributing factor were associated with a higher risk of death (odds ratio [OR]=3.01 and 2.21, respectively). Healthcare organizations need to take actions to enhance nurses’ knowledge and skills to be better engage them in the diagnostic process, such as competency training and assessment.

… Emerg Care … Transitions of care happen multiple times in a patient’s hospital stay and are common times for preventable errors. This study evaluated the impact of errors in the emergency …

… implementation of relative value unit–based payment in a head and neck surgery practice resulted in a higher volume of procedures. The incidence of adverse outcomes, including postoperative hospitalizations, … that the change in payment structure did not impact surgical safety . …