Barcode mediation administration (BCMA) can reduce medication errors, but workarounds can hinder its effectiveness. Using simulations, this study explored potential medication-related errors associated with BCMA during an electronic health record (EHR) transition. The study was able to identify potential problems with both the old and new systems and provide performance data against which to benchmark future system and/or workflow changes.

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.

Checklists are widely used strategies for error reduction and improved communication. This editorial discusses the limitations of checklists for perioperative safety (i.e., when used in isolation or implemented incorrectly) and suggests that safety initiatives taking a systems-oriented approach and organizational buy-in can lead to both perioperative and general safety improvements.

Stressful clinician interactions can diminish the teamwork required to support safe care. This review describes a framework for guiding understanding of how behavioral and emotional responses can affect team behavior, performance, and patient outcomes in the surgical setting. The authors recommend areas of research required to fully understand the phenomenon.

… discussed the literature on health care simulation. … Weinger MB, Banerjee A, Burden AR, et al. Simulation-based …

Distractions and interruptions are prevalent in health care delivery. This conference report reviews types of distractions in anesthesiology, their likelihood to introduce significant risks into care processes, and strategies to help manage distractions.

Time spent with the electronic health record and performing administrative tasks has been linked to physician burnout, an important patient safety problem. This study used direct observation and time diaries to characterize the work of outpatient physicians. Investigators found that physicians spent about one-quarter of their time face-to-face with patients. Nearly half their work day was spent using the electronic health record and doing desk work. Participating clinicians spent 1–2 additional hours on the electronic health record at night. A PSNet interview with lead author Christine Sinsky calls for improving physician work satisfaction in order to improve patient safety.

Emphasizing the value of human factors engineering approaches to improving safety in high-risk industries, this commentary outlines tactics, safety issues, interventions, and outcomes of these methods applied in health care. Interventions described included teamwork training, checklists, and safety culture.

This study found an overall positive safety culture in intensive care units, based on a survey of providers at all levels.

Use of propofol for conscious sedation for pediatric procedures was associated with a very low incidence of adverse events, but the authors caution that these data are derived from institutions with organized sedation services.

This study used real-time, self-reported data collection to demonstrate that interns, more so than residents and attendings, experience emotional stress that is associated with sleep quality and patient load.

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.

Incident reporting systems are ubiquitous, but are limited by low clinician reporting rates and the fact that they identify a relatively small percentage of adverse events. In this feasibility study, a handheld computer-based system for voluntary reporting of medication errors was deployed among physicians and nurses at four academic hospitals. The system demonstrated promise as a supplement to traditional error reporting systems, although even with the increased ease of use, only 16% of clinicians in the study actually reported an error during the study period.

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 prospective multicenter observational study sought to quantify the risk of procedural sedation in children, in whom sedation is much more commonly used than in adults. The participating institutions voluntarily submitted data on more than 30,000 encounters and found that the overall risk of serious adverse events was much lower than that seen in a prior single-center study. However, adverse events with the potential for harm (near misses), such as unanticipated need for bag-mask ventilation or reversal of anesthesia, occurred in 1 of 89 cases. The authors note that, owing to the voluntary nature of the database, these data may be closer to "best practice" than the typical community experience.

This review discusses evidence for the role sleep deprivation plays on performance in both laboratory and clinical settings. The authors define sleep deprivation and summarize past research that suggests the impact is greatest on mood and cognitive tasks rather than motor tasks. They also summarize how fatigue can diminish clinical performance and why this factor poses a significant patient safety concern. Implications from their findings call for greater attention to fatigue in clinical settings and the importance of physicians' acknowledging such states as a risk to their patients rather than a sign of personal weakness. Following publication of this review, two studies evaluated the same relationship in anesthesiology residents and medical interns.

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

The authors describe a method for using a simulated scenario to identify latent failures. Reviewing videotape of the simulation revealed vulnerabilities in the system even though regulations were met.

This study of anesthesiology residents demonstrated that fatigue negatively impairs psychomotor functioning and mood but not measures of clinical performance. Investigators examined, scored, and analyzed the observed behaviors of 12 residents in differing states of prior sleep. The findings support the notion that fatigue can lead to errors as a result of impaired cognitive abilities even if the more difficult to measure clinical performance outcomes were less affected. These findings are the first from a comprehensive simulation study addressing the effects of provider fatigue.