Levy AG, Scherer AM, Zikmund-Fisher BJ, et al. JAMA Netw Open. 2018;1:e185293.
Diagnostic errors and delays may occur when patients fail to disclose medically relevant information. This study analyzed online survey responses from 4510 patients and found that about 70% reported not disclosing information. Disagreement with a clinician's recommendation or failure to understand a clinician's instructions were common. Patients most often did not disclose because they feared judgment from the clinician or felt embarrassed.
Griffiths P, Ball JE, Bloor K, et al. National Institute for Health Research; 2018.
Missed nursing care has been linked to safety problems, but ensuring reliable levels of nurse staffing remains challenging. This report provides the results of a 3-year investigation into whether tracking of vital signs by nursing staff could serve as a viable measure for safe patient coverage. The report identified correlations between low staffing, missed vital sign observation, length of stay, and likelihood of mortality. However, record review found no direct relationship between safety and staffing levels. A PSNet perspective examined the relationship between missed nursing care and patient safety.
Khan A, Spector ND, Baird JD, et al. BMJ. 2018;363:k4764.
Patient engagement in safety takes many forms: patients may report unique safety incidents, encourage adherence to best medical practice, and coproduce improvement initiatives. Family-centered rounding in pediatrics invites families to express concerns, clarify information, and provide real-time input to the health care team. This pre–post study explored the safety impact of family-centered rounds on 3106 admissions in pediatric units at 7 hospitals. Family-centered rounds reduced both preventable and nonpreventable adverse events. They also improved family experience without substantially lengthening rounding time. A past PSNet interview discussed the safety benefits of structured communication between health care providers and family members.
Carayon P, Wooldridge A, Hose B-Z, et al. Health Aff (Millwood). 2018;37:1862-1869.
System and process weaknesses can hinder safe patient care. This commentary raises awareness of human factors engineering as a key opportunity for enhancing patient safety. The authors provide recommendations to drive adoption and spread of human factors strategies through targeted education, clinician–engineer partnerships, and coordinated improvement efforts.
Pérez T, Moriarty F, Wallace E, et al. BMJ. 2018;363:k4524.
Elderly patients are at greater risk of experiencing adverse drug events than the adult population as a whole. Older patients are more likely to be frail, have more medical conditions, and are physiologically more sensitive to injury from certain classes of medication. Researchers examined a large cohort of Irish outpatients age 65 and older to determine the relationship between hospital discharge and potentially inappropriate medication prescribing. Approximately half of the 38,229 patients studied were prescribed a medication in contravention to the STOPP criteria. The risk of potentially inappropriate prescribing increased after hospital discharge, even when using multiple statistical techniques to control for medical complexity. An accompanying editorial delineates various vulnerabilities that predispose older patients to adverse events during the transition from hospital to home. A recent PSNet perspective discussed community pharmacists' role in promoting medication safety.
Nickel WK, Weinberger SE, Guze PA, et al. Ann Intern Med. 2018;169:796-799.
Patient and family engagement can enhance both individual safety and organizational improvement efforts. This position paper advocates for patients and families to be active partners in all aspects of their care, treated with respect and dignity, engaged in improving health care systems, and directly involved in education of health care professionals. The piece also provides strategies to employ these recommendations in the daily practice.
Sloane DM, Smith HL, McHugh MD, et al. Med Care. 2018;56:1001-1008.
Prior research suggests that improved nursing resources may be associated with decreased mortality and adverse events. However, less is known about how changes to nursing resources in the inpatient setting may affect quality and safety over time. In this study involving 737 hospitals and survey data from nurses obtained in 2006 and 2016, researchers found that after adjusting for numerous factors, better nursing resources in terms of work environment, staffing, and education was associated with improvement in quality and patient safety outcomes. A PSNet perspective discussed the impact of nursing resources on patient safety.
Sharma AE, Rivadeneira NA, Barr-Walker J, et al. Health Aff (Millwood). 2018;37:1813-1820.
Patient and family engagement efforts can affect health care quality and safety. This review examined the research on patient engagement efforts and found evidence of robust examinations of patient engagement related to patient self-management of anticoagulation medications. However, there was mixed-quality evidence on patient involvement in medication administration errors, documentation and scheduling accuracy, hospital readmissions, and health care–associated infections. They recommend areas of research needed to guide the application of patient engagement strategies.
Artificial intelligence can improve practice by making synthesized data available in real time to inform frontline decision-making. This commentary describes factors clinicians should consider as artificial intelligence becomes more prevalent in health care and discusses how this technology can enable clinicians to focus on helping patients navigate complex care choices.
Steelman VM, Shaw C, Shine L, et al. Jt Comm J Qual Patient Saf. 2019;45:249-258.
An unintentionally retained foreign object during a surgery or a procedure is considered a never event and can result in significant patient harm. Researchers retrospectively reviewed 308 events involving unintentionally retained foreign objects that were reported to The Joint Commission to better characterize these events, determine the impact on the patient, identify contributing factors, and make recommendations for improving safety.
Ratwani RM, Savage E, Will A, et al. Health Aff (Millwood). 2018;37:1752-1759.
Although health information technology has been shown to improve patient safety, problems with implementation and user interface design persist. Unintended consequences associated with the use of electronic health record (EHR) and computerized provider order entry (CPOE) systems remain a safety concern. Pediatric patients may be particularly vulnerable to medication errors associated with EHR usability. Researchers examined 9000 safety event reports over a 5-year period from 3 pediatric health care facilities and found that 5079 events were related to the EHR and medication. Of these, 3243 identified EHR usability as contributing to the event, 609 of which reached the patient. Incorrect dosing was the most common medication error detected across the three facilities. A previous WebM&M commentary highlighted the unintended consequences of CPOE.
Anticoagulants are commonly prescribed medications that have high potential for harm if administered incorrectly. This review summarizes common errors at the prescribing, dispensing, and administration phases of direct oral anticoagulant therapy. The authors suggest team-based strategies—such as process assessment, policy development, and medication reconciliation—to prevent adverse drug events associated with direct oral anticoagulants.
Aiken LH, Sloane DM, Barnes H, et al. Health Aff (Millwood). 2018;37:1744-1751.
Factors in the hospital work environment can affect nurses' ability to provide safe care. In this survey study, investigators examined trends in nurse ratings of their work environment and patient ratings of care quality at 535 hospitals between 2005 and 2016. Over this time frame, about 20% of hospitals showed significant improvements in work environment scores, while 7% of hospitals demonstrated declining scores. There was an association between an improving work environment and better patient satisfaction. The authors conclude that lack of improvement in work environments may worsen safety culture and impede efforts to enhance patient safety. A PSNet interview with Linda Aiken discussed how nurse staffing and the work environment can affect patient safety and outcomes.
Tubbs-Cooley HL, Mara CA, Carle AC, et al. JAMA Pediatr. 2019;173:44-51.
Excessive nursing workload is a known safety issue. This study examined whether nurse workload in the neonatal intensive care unit affected the quality of nursing care. Investigators measured workload using patient–nurse ratios, taking into account patient acuity, and a convenience sample of nurses also reported their perceived workload. Participating nurses were asked to report the care they provided, and missed care was defined as self-reported failure to provide any of 11 prespecified essential elements of nursing care. The authors identified a consistent association between perceived workload and missed care, suggesting that nurses' own assessments of their workload should be a safety consideration. A PSNet perspective explores how missed nursing care may explain the association between low nurse staffing levels and increased mortality in hospital patients.
Mann S, Hollier LM, McKay K, et al. New Engl J Med. 2018;379:1689-1691.
Maternal morbidity has received increasing attention as a patient safety issue. This commentary recommends four strategies for improving obstetrics safety: focusing on prevention of complications, using multidisciplinary huddles to enhance communication, employing simulation as a teamwork training model, and developing partnerships between hospitals to ensure the best care is available.
Vento S, Cainelli F, Vallone A. World J Clin Cases. 2018;6:406-409.
Malpractice concerns can influence treatment decisions as clinicians seek to avoid errors of omission. This commentary reviews factors that contribute to defensive medicine, underscores the role the blame culture has in perpetuating this behavior, and discusses the costs to patients, physicians, and health systems.
Giardina TD, Haskell H, Menon S, et al. Health Aff (Millwood). 2018;37:1821-1827.
Reducing harm related to diagnostic error remains a major focus within patient safety. While significant effort has been made to engage patients in safety, such as encouraging them to report adverse events and errors, little is known about patient and family experiences related specifically to diagnostic error. Investigators examined adverse event reports from patients and families over a 6-year period and found 184 descriptions of diagnostic error. Contributing factors identified included several manifestations of unprofessional behavior on the part of providers, e.g., inadequate communication and a lack of respect toward patients. The authors suggest that incorporating the patient voice can enhance knowledge regarding why diagnostic errors occur and inform targeted interventions for improvement. An Annual Perspective discussed ongoing challenges associated with diagnostic error.
The Moore Foundation provides free access to this article.
Lam MB, Figueroa JF, Feyman Y, et al. BMJ. 2018;363:k4011.
Accreditation is a widely accepted strategy for ensuring hospital quality and safety. Hospitals accredited by The Joint Commission have been found to have improved performance on care quality metrics. However, few researchers have investigated whether or how accreditation affects patient outcomes. Investigators used Medicare data to assess the relationship between Joint Commission accreditation, other independent accreditation, or state survey review only (no independent accreditation) on patient outcomes and experience. Surgical mortality and readmissions did not differ between hospitals with and without accreditation. For medical conditions, accredited hospitals had a lower readmission rate but no statistically significant difference in mortality rate. Patient experience was modestly better at hospitals without accreditation. These findings may reflect how state survey and independent accreditation have converged in terms of methods and efficacy. A PSNet interview with The Joint Commission's CEO discussed the organization's efforts to use accreditation as one of many tools to promote high reliability in health care.
Boet S, Etherington N, Larrigan S, et al. BMJ Qual Saf. 2019;28:327-337.
Teamwork training enhances health care team performance, especially in crisis situations. This systematic review identified 13 tools for assessing teamwork in high-stress settings, most of which were designed for the emergency department. A past PSNet perspective explored insights learned from experience with the AHRQ-supported teamwork training program, TeamSTEPPS.
Chrouser KL, Xu J, Hallbeck S, et al. Am J Surg. 2018;216:573-584.
Stressful clinician interactions can diminish the teamwork required to support safe care. This review describes a framework for guiding understanding of how behavioral and emotional responses can affect team behavior, performance, and patient outcomes in the surgical setting. The authors recommend areas of research required to fully understand the phenomenon.
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