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Shiell A, Fry M, Elliott D, et al. Intensive Crit Care Nurs. 2022;Epub Aug 25.
Rapid response team (RRT) activations bring together a team of providers to immediately assess and treat a patient who is rapidly deteriorating. This mixed-methods study examined the characteristics of a collaborative RRT model in one Australian tertiary care hospital. The majority of activations occurred in general medicine units and some patients (approximately 5%) had more than five activations. Qualitative interviews with nurses and physicians highlighted how the collaborative RRT model improves patient safety and optimized early detection and management of patient deterioration.
Goodwin C, Haas S, Berry WR. BMJ Leader. 2022;Epub Aug 19.
Disruptive behavior includes behaviors that show disrespect for others and impede safe delivery of patient care. This commentary presents a framework for new physician managers to address disruptive behavior modeled after clinical medicine: diagnose, treat, prevent. The authors stress maintaining curiosity during the “diagnostic” phase, careful consideration of “treatment” and follow-up, and “prevention” of future disruption though intentional training and building a culture of safety.
Vecchione TM, Agarwal R, Monitto CL. Paediatr Anaesth. 2022;32:982-992.
Appropriate pediatric pain management is an ongoing patient safety concern. This article discusses five categories of errors in pediatric acute pain management and how mitigating cognitive biases can help clinicians anticipate, identify, and avoid these errors.
Redelmeier DA, Shafir E. Med Decis Making. 2022;Epub Sep 5.
Premature closure occurs when clinicians accept a diagnosis before it has been confirmed and alternative diagnoses have been explored and can lead to missed diagnosis. In this study, participants (including both health care professionals and community members) were provided one of five scenarios describing a hypothetical patient with symptoms suggestive of COVID-19 in the presence or absence alternative diagnosis (e.g., COVID-19 symptoms and the presence or absence of a positive flu test). Findings suggest that bias can lead individual to overlook the likelihood of COVID-19 when an alternative diagnosis is present.

JAMA. Nov 2021-Sep 2022. 

Diagnostic excellence achievement is becoming a primary focus in health care. This 20 article series covers diagnosis as it relates to the Institute of Medicine quality domains, clinical challenges, and priorities for improvement across the system. 
Burfeind KG, Zarnegarnia Y, Tekkali P, et al. Anesth Analg. 2022;Epub Aug 19.
The American Geriatrics Society (AGS) Beers Criteria serves as a guideline for prescribers to avoid potentially inappropriate medications (PIM) in geriatric patients (age 65 years and older). In this retrospective cohort study, nearly 70% of geriatric patients undergoing elective surgery received at least one PIM identified by the Beers Criteria. Patients, including cognitively impaired and frail patients, who received at least one PIM, had longer length of hospital stay after surgery.
Wise J. BMJ. 2022;378:o1974.
Patients can be vulnerable to having concerns dismissed or being gaslighted as to their legitimacy. Implicit biases against women in both clinical and administrative settings are known to foster conditions for unsafe care. This piece defines the use of the term gaslighting and how it can result in diagnostic delay due to a lack of patient-centered communication and respect.
World Health Organization. September 17, 2022.
Patients, families, and providers around the world are affected by medical error. This annual event and its associated materials seek to raise awareness, motivate collaboration, and stimulate innovative work targeting a distinct patient safety theme. The 2022 theme is “Medication Safety” with the slogan “Medication without Harm". Explicit objectives of the effort include increasing awareness worldwide of the impact of medication errors and enabling a robust patient and family role in medication safety efforts.

Farnborough, UK: Healthcare Safety Investigation Branch; July 7, 2022.

Misuse of insulin pens contributes to never events associated with diabetic medication therapy in hospitalized patients. This investigation of an injurious insulin extraction workaround culminated in recommendations to improve insulin administration safety including the explicit use of pen devices to administer U-500 insulin.
Yale SC, Cohen SS, Kliegman RM, et al. Diagnosis (Berl). 2022;9:348-351.
Diagnostic timeouts can improve the differential diagnosis process and limit missed diagnostic opportunities. This prospective study evaluated the implementation of diagnostic timeouts among eight pediatric hospital medicine providers over a 12-month period. In the majority of cases, the diagnostic timeout led to the pursuit of alternative diagnoses.
Derrong Lin I, Hertig JB. Hosp Pharm. 2022;57:323-328.
The COVID-19 pandemic necessitated urgent changes in all clinical settings including community and hospital pharmacies. This commentary describes global threats to patient safety (rapidly changing clinical evidence, counterfeit medications, drug shortages) and strategies pharmacy leaders can implement to maintain patient safety.

Washington DC; National Quality Forum and Anticoagulation Forum; 2022.

Warfarin and other anticoagulants are high-alert medications that, if errors occur in their use, can result in considerable harm. This document advocates that a stewardship approach be applied to anticoagulant therapy to reduce the risk of adverse events and discusses steps to implement and sustain a program to guide the safe, effective use of anticoagulants.
Soto C, Dixon-Woods M, Tarrant C. Arch Dis Child. 2022;Epub Jul 21.
Children with complex medical needs are vulnerable to patient safety threats. This qualitative study explored the perspectives of parents with children living at home with a central venous access device (CVAD). Parents highlight the persistent fear of central line-associated blood stream infections as well as the importance of maintaining a sense of normalcy for their children.
Factora F, Maheshwari K, Khanna S, et al. Anesth Analg. 2022;135:595-604.
Rapid response teams (RRT) are designed to intervene at the earliest signs of clinical deterioration to prevent intensive care unit transfer, cardiac arrest, or death. This study presents the changes of in-hospital mortality rates following implementation of RRT, introduction of anesthesiologist-led RRT, and other policy changes. Results indicate a gradual decline of in-hospital mortality in the nine-year period following RRT introduction.
Tsilimingras D, Natarajan G, Bajaj M, et al. J Patient Saf. 2022;18:462-469.
Post-discharge events, such as medication errors, can occur among pediatric patients discharged from inpatient settings to home. This prospective cohort, including infants discharged from one level 4 NICU between February 2017 and July 2019, identified a high risk for post-discharge adverse events, (including procedural complications and adverse drug events) and subsequent emergency department visits or hospital readmissions. Nearly half of these events were due to management, therapeutic, or diagnostic errors and could have been prevented.

Building Trust and the ABIM Foundation. Addressing the Loss of Trust in Safety Culture. September 13, 2022. 4:00 PM (eastern). 

Trust in patient safety processes encourages reporting of concerns, learning from error, and development of safety-focused patient/family partnerships. This session will discuss how criminal actions against clinicians who err, challenge the balance needed to ensure that patients can trust the health care system to hold those accountable when error occurs, while enabling clinicians to trust their reported mistakes to be managed appropriately.
Kandaswamy S, Grimes J, Hoffman D, et al. J Patient Saf. 2022;18:430-434.
Despite widespread implementation of computerized provider order entry (CPOE) for medication ordering, some orders may be submitted wholly or in part using the free-text field. This study analyzed CPOE orders that included medication information in the free text field. High-risk medications (e.g., insulin, heparin) were frequently mentioned and the most common expected action was to discontinue. Despite using the same CPOE software, there were wide variations between the six included hospitals in the rates of orders in free text and the types of medications mentioned.

A 2-year-old girl presented to her pediatrician with a cough, runny nose, low grade fever and fatigue; a nasal swab for SARS-CoV-2 and influenza was negative and lung sounds were clear. The patient developed a fever and labored breathing and was taken to the Emergency Department (ED) before being admitted to the hospital. She developed respiratory distress and clinically worsened over time until she developed respiratory failure requiring air transportation to the pediatric intensive care unit at a children’s hospital.