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Organization: Duke University Health System Patient Safety Center
Event Description: Ten week course (one hour per week) about the science and practice of well-being for healthcare workers and others. Attendees will learn strategies that can enhance their own well-being, and through sharing, the well-being of their co-workers.
Event Location: Online
Date: September 21 – November 23, 2021
Event Fee:
CE or CME Offered?
Gregory H, Cantley M, Calhoun C, et al. Am J Emerg Med. 2021;46:266-270.
Medication safety continues to be a challenge in most healthcare settings, including emergency departments. In this academic emergency department, an overall error rate of 16.5% was observed, including errors in directions, quantity prescribed, and prescriptions written with refills. Involving a pharmacist at discharge may increase patient safety.
Liukka M, Hupli M, Turunen H. Leadersh Health Serv (Bradf Engl). 2021;Epub Sep 8.
The Hospital Survey on Patient Safety Culture and Nursing Home Survey on Patient Safety Culture were used in one Finish healthcare organization to assess 1) differences in employee perceptions of safety culture in their respective settings, and 2) differences between professionals’ and managers’ views. Managers assessed safety culture higher than professionals in both settings. Acute care patient safety scores were significantly positive in 8 out of twelve domains, compared to only one in long-term care.
Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. Infect Control Hosp Epidemiol. 2021;Epub Sept 13.
Using data reported to the National Healthcare Safety Network, this study identified significant increases in the incidence of healthcare-associated infections from 2019 to 2020. The authors conclude that these findings suggest a need to return to conventional infection control and prevention practices and prepare for future pandemics.

ISMP Medication Safety Alert! Acute care edition.  September 9, 2021;26(18);1-5.

Disrespectful behavior is a persistent contributor to failures in medical care. This article summarizes influences that enable the acceptance and perpetuation of unprofessional behaviors and calls for data to assess its presence and impact in health care environments. The deadline for survey participation is October 29, 2021.
Barber Doucet H, Ward VL, Johnson TJ, et al. Clin Pediatr (Phila). 2021;60(9-10):408-417.
Healthcare provider implicit biases can lead to inequitable care delivery and poorer patient outcomes. Pediatric residents were surveyed about their attitudes, skill level, and preferred educational interventions related to implicit bias and care of diverse populations. Prior medical education or training in diversity and bias-related skills was associated with higher self-reported skill level.
Sidi A, Gravenstein N, Vasilopoulos T, et al. J Patient Saf. 2021;17(6):e490-e496.
Nontechnical skills, such as teamwork and communication, can influence performance in technical fields like surgery or emergency medicine. This study found that simulation-based assessments can measure improvements in nontechnical skills and cognitive performance among residents.

Mirtallo JM, Ayers P. Pharmacy Practice News. September 7, 2021;48(9):17-20.

Parenteral nutrition (PN) processes contain various steps that are prone to errors resulting in patient harm. This article discusses standardization as a strategy to reduce the potential for missteps and shares resources for process evaluation to improve PN reliability and safety.
Grailey K, Leon-Villapalos C, Murray E, et al. BMJ Open. 2021;11(8):e046699.
Psychological safety enables staff to raise concerns, reduce mistakes and learn from errors. The majority of surveyed intensive care unit staff in three units within one trust in London reported feeling psychologically safe within their teams (e.g. being able to bring up problems). In a novel finding, this study identified potential negative consequences of psychological safety, including distraction and fatigue for team leaders.
Warm EJ, Ahmad Y, Kinnear B, et al. Acad Med. 2021;96(9):1268-1275.
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.
Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478(6):1179-1185.
Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.
Combs CA, Einerson BD, Toner LE. Am J Obstet Gynecol. 2021;Epub Jul 30.
Maternal and newborn safety is challenged during cesarean delivery due to the complexities of the practice. This guideline recommends specific checklist elements to direct coordination and communication between the two teams engaged in cesarean deliveries. The guideline provides a sample checklist and steps for its implementation.
Boquet A, Cohen T, Diljohn F, et al. J Patient Saf. 2021;17(6):e534-e539.
This study classified flow disruptions affecting the anesthesia team during cardiothoracic surgeries. Disruptions were classified into one of six human factors categories: communication, coordination, equipment issues, interruptions, layout, and usability. Interruptions accounted for nearly 40% of disruptions (e.g., events related to alerts, distractions, searching activity, spilling/dropping, teaching moment).
Van Slambrouck L, Verschueren R, Seys D, et al. J Prof Nurs. 2021;37(4):765-770.
An online survey of nursing students in Belgium found that about one in three students were involved in a patient safety incident during their clinical training, and the majority experienced emotional distress after the event. Medical and nursing curriculum should include opportunities for competency development to support peers involved in patient safety incidents.
Kaya GK. Appl Ergon. 2021;94:103408.
A systems approach provides a framework to analyze errors and improve safety. This study uses the Systems Theoretic Process Analysis (STPA) to analyze risks related to pediatric sepsis treatment process. Fifty-four safety recommendations were identified, the majority of which were organizational factors (e.g., communication, organizational culture).

Thomas K, Gebeloff R, Silver-Greenberg J. New York Times. September 11, 2021.

Nursing home medication misuse is a contributor to resident harm. This story highlights system influences such as staffing shortages, reporting failures and normalization of prescribing behaviors that coincide with the misuse of antipsychotic medications and overdiagnosis of schizophrenia.
Shervani S, Madden W, Gleason LJ. JAMA Intern Med. 2021;Epub Aug 31.
Prior research has found that electronic health record systems (EHRs) cannot effectively communicate medication discontinuation instructions to pharmacies. This “teachable moment” commentary highlights this issue with EHR and pharmacy system interoperability which resulted in the inadvertent dispensing of a discontinued medication. A related commentary discusses the challenges associated with attempting to discontinue prescriptions and how the CancelRx system can help mitigate these challenges.

Rockville, MD: Agency for Healthcare Research and Quality; September 9, 2021. PA-21-267. 

This funding opportunity supports large research demonstration and implementation projects applying existing strategies to understand and reduce adverse events in ambulatory and long-term care settings. Projects focused on preventing harm in disadvantaged populations to improve equity are of particular interest. The funding cycle will be active through May 27, 2024.
D'Angelo JD, Lund S, Busch RA, et al. Surgery. 2021;170(2):440-445.
This study evaluated the type and effectiveness of resident and faculty coping strategies following an intraoperative error and the interaction with physician gender. Results show that while men and women surgeons experience adverse events at approximately the same rate, the coping methods utilized and effectiveness of the methods varied.