Improving diagnosis in pediatrics is an ongoing patient safety focus. This retrospective study included 129 pediatric emergency transfer cases and examined the relationship between missed opportunity for improvement in diagnosis (MOID; determined using SaferDx) and patient outcomes. Researchers found that MOID occurred in 29% of emergency transfer cases and it was associated with higher risk of mortality and longer post-transfer length of stay.

Many patients were unable to access care during the pandemic, particularly during surges. This longitudinal cohort study in the UK reports that 35% of participants reported disrupted access to care (e.g., cancelled or postponed appointments or procedures). While overall rates of potentially preventable hospitalization were low (3%), those who reported disrupted access had increased risk of potentially preventable hospitalization.

Patients who experience life-changing adverse events due to errors, and their families, typically want disclosure of the error and appropriate accountability. This systematic review identified 41 studies exploring the views of those affected by adverse events. Four themes were identified: transparency, person-centeredness, trustworthiness, and restorative justice. Applying these themes to investigations may result in ensuring the process and outcomes are experienced as "fair" to those impacted.

Missed recognition of early signs of clinical deterioration can result in transfer to the intensive care unit (ICU) or death. This study investigated whether critical illness events (transfer to ICU or death) impacted another patient's critical illness event in the subsequent six-hour period. Results suggest one or more critical illness events increase the odds of additional patient transfers into the ICU, but not of death. The authors present several explanations for this phenomenon.

Diagnostic errors in pediatrics remain a significant focus of patient safety. This study uses two years of unplanned readmissions to a children’s hospital to identify missed opportunities for improving diagnosis (MOID). Clinician decision-making and diagnostic reasoning were identified as key factors for MOID. The authors recommend that future research include larger cohorts to identify populations and conditions at increased risk for MOID-related readmissions.

… Eur J Hosp Pharm … Critical care patients may be vulnerable to …

Missed diagnostic opportunities often involve multiple process breakdowns and can lead to serious avoidable patient harm. Based on a web-based survey of 1,594 emergency medicine physicians, missed diagnostic opportunities most frequently occur in children who present to the emergency department with undifferentiated symptoms (e.g., abdominal pain, fever, vomiting) and often involve issues related to the patient/parent-provider interaction, such as misinterpreting patient history or inadequate physical exam.

Debriefing after clinical events is an important opportunity for critical learning, process improvement, and enhancing team communication. This systematic review of 21 studies synthesized findings regarding the attributes and evidence supporting the use of clinical debriefing tools. While all of the evaluated tools included points related to education and evaluation, few tools included a process for implementing change or addressed staff emotions. The authors include recommendations for clinicians, educators and researchers for teaching, implementing and evaluating clinical debriefing tools.

Prisons present unique challenges in providing, as well as in measuring, safe patient care. This article describes structures and processes within prison systems that may contribute to avoidable harm, such as limited staffing and security to travel to healthcare appointments. The result is a two-tier definition taking into consideration the unique context of prison healthcare.

Patients and clinicians may hold implicit gender biases and rate women clinicians more negatively. In this study, adverse event reports written about residents were reviewed to determine if resident gender was associated with different types and frequency of incident reports. The most comment complaint about men physicians involved a medical error, while the most common complaint type about women included a communication-related event. Additionally, women were more frequently identified by name only, without a title such as “doctor”.

Patient safety learning laboratories (PSLL) encourage a cross-disciplinary, collaborative approach to problem solving. This study reports on how a learning ecosystem supported the success of three distinct PSLLs. Qualitative and quantitative results reveal four types of alignment and supporting practices that contribute to the success of the learning laboratories.

… and staff members. … Galiatsatos P, O'Conor KJ, Wilson C, et al. A checklist to address implicit bias in healthcare …

… on this relationship is warranted. … Casalino LP, Li J, Peterson LE, et al. Relationship between physician burnout …

Improving patient safety is a global goal. This literature review explored patient safety interventions focused on people living in fragile, conflict-affected, and vulnerable settings. Studies were generally from lower and lower-middle income countries and focused primarily on strengthening infection prevention and control; however, there is a call for more attention on providing patient safety training to healthcare workers, introducing risk management tools, and reducing preventable harm during care delivery.

Children with complex home care needs are vulnerable to medication errors. This guideline suggests strategies to enhance medication safety at home that include focusing on health literacy, prescriber actions, dosing tool appropriateness, communication, and training of caregivers. 

Incomplete or delayed referrals from primary care providers to specialty care can cause diagnostic delays and patient harm. A systems engineering analysis was conducted to identify vulnerabilities in the referral process and develop a framework to close the loop between primary and specialty care. Low reliability processes, such as workarounds, were identified and human factors approaches were recommended to improve successful referral rates.

… J Am Med Inform Assoc … Problem lists , while an important … which needs further study. … Grauer A, Kneifati-Hayek J, Reuland B, et al. Indication alerts to improve problem list documentation. J Am Med Inform Assoc. Epub 2021 Dec 28. …

… successfully leveraged during the COVID-19 pandemic . … Phillips RA, Schwartz RL, Sostman HD, et al. Development and …

Artificial intelligence (AI) has been used and studied in multiple healthcare processes, including detecting patient deterioration and surgical decision making. This literature review focuses on studies using AI to detect breast cancer in mammography screening practice. The authors recommend additional prospective studies before using artificial intelligence in clinical practice. 

Nosocomial transmission of COVID-19 is an ongoing concern given the pressures faced by hospitals and healthcare workers during the pandemic. This observational study using data from four hospitals in the United Kingdom found that patients with hospital-onset COVID-19 (compared to suspected community-acquired infections) are associated with high risk of nosocomial transmissions to other patients and healthcare workers.