Error management training (EMT) encourages learners to make errors during training, and then engage in positive discussions about recognition of those errors. This commentary calls for increased use of EMT for surgical students and residents to promote error recovery.

Healthcare professionals who are involved in patient safety incidents can experience psychological distress. Using three case examples from surgery, urology, and maternity care, this study explored the emotional experience of healthcare professionals involved in patient safety incidents. The authors discuss the importance of providing support for recovery after involvement in a patient safety incident and protecting professionals from workplace pressures.

A 2012 review estimated that diagnostic errors in the intensive care unit (ICU) may contribute to up to 8% of patient deaths. This narrative review identifies common causes of diagnostic error (e.g., cognitive bias) and suggests a diagnostic framework. Cognitive de-biasing strategies and increasing time spent with the patient are recommended as strategies for reducing diagnostic errors in this vulnerable patient population.

Research has identified variations in treatment that are unlikely to be related to patient characteristics, such as region. In this study, surgeons describe their preferences for and experiences with a device which caused widespread harm to women and was ultimately recalled by several patient safety agencies: transvaginal mesh for the treatment of pelvic floor devices in women. Even when surgeons arrived at the same decision (to perform surgery or not), wide variations were observed during the decision-making process.

Racism is increasingly seen as a major contributor to poor maternal care and adverse outcomes. This article summarizes racial health disparities impacting patients in the neonatal intensive care unit (NICU) and interventions to reduce racial bias in the NICU.

Prehospital medication administration for pediatric patients is complicated by the need to obtain an accurate weight for correct dosing. This retrospective analysis examined prehospital medication dosing in children 12 years of age and younger after implementation of a statewide emergency medical services (EMS) pediatric dosing reference. Despite implementation of written guidelines, researchers found that 35% of prehospital medication administrations involved a dosing error. Dosing errors were most common for hyperglycemia reversal medications, opioids, and one type of bronchodilator (Ipratropium bromide).

A missed or delayed diagnosis of stroke places patients at risk of permanent disability or death. This article describes how interdisciplinary teams used a failure modes, effects, and criticality analysis (FMECA) to create an acute stroke diagnostic process map, identify failures, and highlight existing safeguards. The FMECA process identified several steps in the diagnostic process as the most critical failures to address, including failure to screen patients for stroke soon after presentation to the Emergency Department (ED), failure to obtain an accurate history, and failure to consider a stroke diagnosis during triage.

Cognitive biases are a known source of misdiagnosis and post-operative complications. This review sought to identify the impact of cognitive biases on surgical performance and patient outcomes. Through thematic analysis of 39 studies, the authors identified 31 types of cognitive bias across six themes. Importantly, none of the included studies investigated the source of cognitive bias or mitigation strategies.

Safe obstetrical care can be compromised by a variety of controllable risk factors, such as communication between providers. To reduce preventable adverse events, interprofessional obstetric teams (physicians and midwives) in one hospital received training on the importance of team communication. Compared to the year before the training, there was a significantly significant reduction in diagnostic errors and inadequate birth position, but not in other categories.

Medication errors can happen at any step along the medication pathway, from ordering to administration. This study focuses on ordering errors reported to the AHRQ Network of Patient Safety Databases (NPSD) from 2010 to 2020. The most common categories of ordering errors were incorrect dose, incorrect medication, and incorrect duration; nearly 80% of errors were definitely or likely preventable.

The COVID-19 pandemic led to unprecedented numbers of patients seen in the emergency department (ED), some who had COVID-19, some who had a different diagnosis, and some who had both. This study analyzes patients who presented to the ED with COVID-19 and signs of another diagnosis that was missed. Approximately one-third of patients with a second concurrent diagnosis experienced a diagnostic delay. Factors that may have influenced the missed diagnosis include ED overcrowding and anchoring heuristics.

Variations in diagnostic process application reduce the safety of care. This commentary discusses how clinician engagement, community partnerships, and connected care (e.g., telehealth) should interface to improve diagnosis for patients impacted by disparities and implicit bias.

Missteps in the labeling and registration of child injury as abuse can result in harm for patients and families. This article discusses the impact of implicit bias on reporting actions and shares tactics to minimize the influence of cognitive error on recognizing and reporting of child mistreatment.

Patients with mental illness may receive lower quality healthcare care than patients without mental illness. In this review of implicit and explicit biases of healthcare providers, the majority demonstrated unfavorable clinical decisions towards patients with mental illness. A prior WebM&M describes how diagnostic overshadowing of a patient with substance use disorder led to undertreatment of a cardiovascular condition.

Electronic health records (EHR) may have unintended negative consequences on patient safety. This review identified 11 articles focused on the relationship between EHR use and diagnostic error. EHR issues fell into three general areas: information gathering, medical decision-making, and plan implementation and communication. The majority of issues were a related to providers’ cognitive processing, revealing an important area of research and quality improvement.

Cognitive aids, such as checklists and decision aids, can reduce omissions in care and improve patient safety. This systematic review including 13 randomized trials found that cognitive aids in clinical emergencies reduced the incidence of missed care steps (from 43% to 11%) and medical errors, and improved teamwork, non-technical, and conflict resolution scores.

Unprofessional and disruptive behavior can erode patient safety and safety culture. The Co-Worker Observation System (CORS), a peer-to-peer feedback program previously used with physicians and advance practice providers, was implemented for use with nurses in three hospitals. Reports of unprofessional behavior submitted to the internal reporting system were evaluated by the CORS team, and peer-to-peer feedback was given to the recipient. This pilot study demonstrated that the implementation bundle can be successful with nursing staff.

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.