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Prevalence, contributory factors and severity of medication errors associated with direct-acting oral anticoagulants in adult patients: a systematic review and meta-analysis.

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Al Rowily A, Jalal Z, Price MJ, et al. Eur J Clin Pharmacol. 2022;78:623-645.

Although direct acting oral anticoagulants (DAOCs) are generally considered safer than older anticoagulants, they are still high-risk medications. This review found that between 5.3% and 37.3% of patients experienced either a prescription, administration, or dosing error. Prescribing errors constituted the majority of error types, and common causes were active failures, including wrong drug or wrong dose.

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

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January 11, 2022

Diagnostic error has been increasingly recognized as an important and evolving patient safety issue. This Primer applies well-established principles of diagnostic error and improvement of diagnostic accuracy to the topic of COVID-19.

Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using reason's accident causation theory.

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Haque H, Alrowily A, Jalal Z, et al. Int J Clin Pharm. 2021;43:1693-1704.

While direct oral anticoagulants (DOAC) are considered safer than warfarin, DOAC-related medication errors still occur. This study assesses the frequency, type, and potential causality of DOAC-related medication errors and the nature of clinical pharmacist intervention. Active, rather than latent, failures contributed to most errors.

Communicating certainty in pathology reports: interpretation differences among staff pathologists, clinicians, and residents in a multicenter study.

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Gibson BA, McKinnon E, Bentley RC, et al. Arch Pathol Lab Med. 2022;146:886-893.

A shared understanding of terminology is critical to providing appropriate treatment and care. This study assessed pathologist and clinician agreement of commonly-used phrases used to describe diagnostic uncertainty in surgical pathology reports. Phrases with the strongest agreement in meaning were “diagnostic of” and “consistent with”. “Suspicious for” and “compatible with” had the weakest agreement. Standardized diagnostic terms may improve communication.

Effectiveness of using simulation in the development of clinical reasoning in undergraduate nursing students: a systematic review,

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Theobald KA, Tutticci N, Ramsbotham J, et al. Nurse Educ Pract. 2021;57:103220.

Simulation training is often used to develop clinical and nontechnical skills as part of nursing education. This systematic review found that repeated simulation exposures can lead to gains in clinical reasoning and critical thinking. Two emerging concepts – situation awareness and teamwork – can enhance clinical reasoning within simulation. With more nursing schools turning to simulation to replace clinical site placement, which is in short supply, understanding of simulation in training is critical.

Nurse bias and nursing care disparities related to patient characteristics: a scoping review of the quantitative and qualitative evidence

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Groves PS, Bunch JL, Sabin JA. J Clin Nurs. 2021;30:3385-3397.

While many studies have been conducted on implicit bias in healthcare, a gap exists in nurse-specific bias and impact on disparities. This scoping review identified 215 research reports on nurse bias and/or care disparities. Most were descriptive in nature and only 12 included evaluating an intervention designed to reduce nurse-related bias. Recommendations for future research include development and testing of interventions designed to reduce nurse-related bias.

Inattentional blindness in anesthesiology: a gorilla is worth one thousand words.

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De Cassai A, Negro S, Geraldini F, et al. PLoS One. 2021;16:e0257508.

Inattentional blindness occurs when individuals miss an unexpected event due to competing attentional tasks. This study asked anesthesiologists to review the anesthetic management of five simulated cases, one of which included the image of a gorilla in the radiograph, to evaluate inattentional blindness. Only 4.9% of social media respondents reported an abnormality, suggesting that inattentional blindness may be common; the authors suggest several strategies to reduce this error.

Factors associated with wrong blood in tube errors: an international case series - The BEST collaborative study.

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Dunbar NM, Kaufman RM. Transfusion (Paris). 2022;62:44-50.

Wrong blood in tube (WBIT) errors can be classified as intended patient drawn/wrong label applied or wrong patient/intended label applied. In this international study, errors were divided almost evenly between the two types and most were a combination of protocol violations (e.g. technology not used or not used appropriately) and slips/lapses (e.g., registration errors). Additional contributory factors and recommendations for improvement are also discussed.

The influence of the availability heuristic on physicians in the emergency department.

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Ly DP. Ann Emerg Med. 2021;78:650-657.

A common type of diagnostic error is availability bias, or diagnosing a patient based on experiences with past similar cases. This study examined whether an emergency physician’s recent experience of a patient presenting with shortness of breath and diagnosed with pulmonary embolism increased subsequent pulmonary embolism diagnoses. While pulmonary embolism diagnosis did increase over the following ten days, that effect did not persist over the 50 days following the first 10 days.

Health disparities: impact of health disparities and treatment decision-making biases on cancer adverse effects among black cancer survivors.

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Vo J, Gillman A, Mitchell K, et al. Clin J Oncol Nurs. 2021;25:17-24.

Racial and ethnic disparities in healthcare can affect patient safety and contribute to adverse health outcomes. This review outlines the impact of health disparities and treatment decision-making biases (implicit bias, default bias, delay discounting, and availability bias) on cancer-related adverse effects among Black cancer survivors. The authors identify several ways that nurses may help mitigate health disparity-related adverse treatment effects, such as providing culturally appropriate care; assessing patient health literacy and comprehension; educating, empowering, and advocating for patients; and adhering to evidence-based guidelines for monitoring and management of treatment-related adverse events. The authors also discuss the importance of ongoing training on the impact of structural racism, ways to mitigate its effects, and the role of research and implementation to reduce implicit bias.

Do my feelings fit the diagnosis? Avoiding misdiagnoses in psychosomatic consultation services.

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Seidl E, Seidl O. J Healthc Risk Manag. 2021;41:9-17.

Diagnostic safety is a patient safety priority across all medical specialties. Over a five-year period, researchers found that 15% of patients referred for psychosomatic consultations at one university hospital were misdiagnosed. Misdiagnosis was primarily attributed to availability bias or other biases. Semi-structured interviews with referring physicians highlight the contributing role of physician attitudes and unusual clinical features.

‘They treat me like I’m old and stupid’: seniors decry health providers’ age bias.

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Graham J. Kaiser Health News. October 20, 2021.

Implicit biases permeate decision making and can impede safe and effective diagnosis and treatment. This story examines how ageism results in undertreatment, mistakes, poor communication and care rationing.

Racial disparities in child abuse medicine.

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Rosenthal CM, Parker DM, Thompson LA. JAMA Pediatr. 2022;176:119-120.

The care of child abuse victims is affected by resource, racial and infrastructure challenges. This commentary describes how the systemic weaknesses catalyzed by poor data collection approaches contribute to misdiagnosis and suggests that successes be mined to minimize the proliferation of continued disparities in this patient population.

Awareness of human factors in the operating theatres during the COVID-19 pandemic

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October 27, 2021

Understanding the ways in which human factors, such as non-technical skills, influence individual and team performance can ultimately improve patient safety, particularly in high-intensity settings such as operating rooms.

The Hidden Danger of Unseen Intravenous Catheters

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October 27, 2021

A 6-week-old infant underwent a craniotomy and excision of abnormal brain tissue for treatment of hemimegalencephaly and epilepsy.

To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room

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October 27, 2021

A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution.

The effects of three consecutive 12-hour shifts on cognition, sleepiness, and domains of nursing performance in day and night shift nurses: a quasi-experimental study.

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James L, Elkins-Brown N, Wilson M, et al. Int J Nurs Stud. 2021;123:104041.

Many hospitals have adopted a 12-hour work shift for nurses and some studies have shown a resulting increase in burnout and decrease in patient safety. In this study, researchers assessed simulated nursing performance, cognition, and sleepiness in day nurses and night nurses who worked three consecutive 12-hour shifts. Overall results indicated nurses on both shifts mostly maintain their abilities on the simulated nursing performance assessment despite reporting increased sleepiness and fatigue. However there was more individual variation in cognition and some domains of performance.

Mix-ups between the influenza (Flu) vaccine and COVID-19 vaccines.

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ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares reported vaccine errors and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.

Analysis of consistency in emergency department physician variation in propensity for admission across patient sociodemographic groups.

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Khidir H, McWilliams JM, O’Malley AJ, et al. JAMA Netw Open. 2021;4:e2125193.

While racial, ethnic, and gender biases have been widely documented at the system level, it has not been well documented at the individual physician level. This analysis of 4.5 million emergency department visits in the US showed variation in hospital admission rates among physicians, but an individual physician’s propensity to admit patients did not vary by patient sociodemographic group.

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