Numerous factors can hinder safe radiology practices, such as communication failures and image interpretation errors. Based on semi-structured interviews with 17 radiologists in Sweden, this study identified 20 themes at the individual-, organization-, technology-, task-and environment-levels describing factors supporting patient safety in radiology. Factors described by participants included the use of standardized tools and work routines (e.g., checklists), handoffs, and incident reporting systems.

Surgical site infections (SSI) are a common, yet largely preventable, complication of surgery which can result in increased length of stay and hospital readmission. In this review of 57 studies, the cumulative incidence of SSI was 11% in adult general surgical patients and was associated with increased length of stay (with variation by types of surgery).

Nontechnical skills such as teamwork and communication can influence surgical performance. This Australian hospital implemented a team training program for surgical teams focused on improving individual and shared situational awareness which led to improvements in nontechnical skills.

… making; and lack of provider training. … Manias E, Bucknall T, Hutchinson A, et al. Resident and family …

Medication safety, particularly among older adults who may have complex medication regimens, is an ongoing safety concern. This study explored medication safety behaviors among young-old (65-74 years), middle-old (75-84 years) and old-old (>85 years) adults. The authors found that older adults are willing to engage in medication safety behaviors, but that preferred behaviors (e.g., verbal behaviors, self-administering medication, reviewing medication charts) differed among the age groups.

Interprofessional communication is critical to safe medication management during transitions of care. Researchers conducted this ethnographic study to explore inter- and intra-professional communications during older adults’ transitions of care. Communication was influenced by the transferring setting, receiving setting, and ‘real-time’ communication. Lack of, or poor, communication impacted medication safety; researchers recommend more proactive communication and involvement of the pharmacist.

Medication administration errors are common and account for a significant fraction of medication errors. This systematic review examined the effect of medication double-checks on medication administration errors. Investigators identified 13 studies (3 were considered high-quality) that demonstrated variable adherence to double-checking protocols. Only one high-quality study showed improvement in medication administration error rates when a double-check took place. No studies demonstrated differences in patient harm with double-checking compared to usual medication administration practice. The authors call for higher-quality studies to determine whether the time-intensive practice of double-checking medication administration confers a meaningful safety benefit. A previous WebM&M commentary discussed an incident involving a nurse who bypassed the double-check policy for verifying the order prior to administration, which led to a medication administration error.

… of elderly patients during care transitions. … Manias E, Bucknall T, Hughes C, Jorm C, Woodward-Kron R. Family …

Early detection of patient deterioration remains an elusive patient safety target. This scoping review examined how nurses employ early warning scoring systems that prompt them to call rapid response teams. Investigators identified 23 studies for inclusion. Barriers to effective identification and treatment of patient deterioration included difficulty implementing early warning score systems, overreliance on numeric risk scores, and inconsistent activation of rapid response teams based on early warning score results. They recommend that nurses follow scoring algorithms that calculate risk for deterioration while supplementing risk scoring with their clinical judgment from the bedside. A WebM&M commentary highlighted how early recognition of patient deterioration requires not only medical expertise but also collaboration and communication among providers.

Rapid response teams are well established in adult and pediatric hospitals. As part of efforts to increase patient engagement in safety efforts, some hospitals allow patients to summon the team directly. This qualitative study of patients and caregivers at two Australian hospitals identified significant barriers to family-activated rapid response teams. Principally, patients did not feel they had the knowledge to make a clinical decision regarding their care and expressed concern about overriding the clinical staff's decisions.

This qualitative study of hospitalized patients in Sweden found that patients expressed interest in engaging in their care. Themes included shared decision-making and increasing patient understanding of health conditions. Patients also expressed concern about the power dynamic between patients and providers and uncertainty about how to best participate in their own hospital care.

Efforts to improve the safety of handoffs have focused on standardizing the signout process. In this mixed methods study, researchers observed 185 anesthetist-to-nurse handoffs from the operating room to the postanesthesia care unit across 3 hospitals. They then conducted focus groups to better understand aspects of safe handoff practices. This work led to the development of a more standardized handoff structure.

This study of an after-hours rapid response team found that the team was not always activated as intended. More unplanned admissions to intensive care were identified following rapid response implementation, possibly due to enhanced surveillance for clinical deterioration. Under-utilization of rapid response may account for mixed results in improving patient safety.

In contrast to a recent study that showed no change in postoperative morbidity and mortality following checklist adoption, this systematic review explored the evidence and found that checklist implementation was linked to a reduction in overall surgical complications. The authors recommend that checklists be used with other interventions to augment safety.

Interruptions were associated with an increased risk of miscommunication between team personnel during surgical procedures. Teams that had limited experience working together seemed to be particularly vulnerable to miscommunications.

In this study, conducted at seven hospitals in three countries, nearly one-third of patients seen by a rapid response team ultimately had limitations placed on their care (such as do-not-resuscitate orders). This finding indicates a need for improved advanced care planning.

This qualitative study, based on direct observation of 160 surgical procedures, found that communication breakdowns were significantly correlated with deviations from the expected length of the procedure.

This review analyzed 12 studies focused on team training in surgical settings, and found before-and-after implementation improvements in team practices and complication rates. However, similar to a past review, the authors highlight limitations in study design and the need for additional research on team training strategies.

Finding limited evidence that rapid response systems prevent adverse clinical outcomes, this review explores how to improve their effectiveness.