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Validation of the second victim experience and support tool-revised in the neonatal intensive care unit.

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Winning AM, Merandi J, Rausch JR, et al. J Patient Saf. 2021;17:531-540.

Healthcare professionals involved in a medical error often experience psychological distress. This article describes the validation of a revised version of the Second Victim Experience and Support Tool (SVEST-R), which was expanded to include measures of resilience and desired forms of support.

The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps

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January 7, 2022

A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several different providers (pre-operative nurse, resident physician, attending physician, and anethesiology team) to help prepare her for the procedure. In the OR, the surgical team performed two separate time-outs while the patient was being prepped, placed under general anesthesia, and draped.

Race differences in reported "near miss" patient safety events in health care system high reliability organizations.

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Thomas AD, Pandit C, Krevat SA. J Patient Saf. 2021;17:e1605-e1608.

Building on prior research, this study identified racial differences in voluntarily reported near-miss events. Compared to white patients, black patients had fewer reported events but were more likely to experience near-miss events related to laboratory/specimen handling, blood bank, and safety/security.

Maternal mortality: near-miss events in middle-income countries, a systematic review.

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Heitkamp A, Meulenbroek A, van Roosmalen J, et al. Bull World Health Organ. 2021;99:693-707F.

Maternal safety is a patient safety priority. According to this systematic review including 69 studies, the maternal near miss incidence rate is estimated to be 15.9 cases per 1,000 live births in lower-middle income countries and 7.8 cases per 1,000 live births in upper-middle-income countries. The most common causes of near miss were obstetric hemorrhage and hypertensive disorders.

Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting.

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Webster KLW, Stikes R, Bunnell L, et al. J Perinat Neonatal Nurs. 2021;35:258-265.

Infant misidentification or abduction are considered never events. This article discusses the results of a failure mode and effects analysis to identify and eliminate or reduce the risk of infant misidentification or abduction. Twenty-eight failure modes were identified; the highest-ranked items involved concerns for uninvited individuals on the unit, interactions with child-protective services, alarm fatigue, and inadequate identification checks of the infants with mothers.

New Horizons in Patient Safety. Safe Communication: Evidence-based Core Competencies with Case Studies from Nursing.

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Hannawa AF, Wendt AL, Day LJ. Berlin, GER: Walter De Gruyter; 2018. ISBN: 9783110453041.

Poor communication is often associated with unsafe medical care. This companion volume uses the case study format to illustrate nursing communication practices to be targeted by education strategies to improve patient safety.

Safety implications of different forms of understaffing among nurses during the COVID-19 pandemic.

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Andel SA, Tedone AM, Shen W, et al. J Adv Nurs. 2021;78:121-130.

During the first weeks of the COVID-19 pandemic, 120 nurses were surveyed about nurse-to-patient staffing ratios, skill mix, and near misses in their hospitals. Personnel understaffing led to increased use of workarounds, and expertise understaffing led to increased cognitive failures, both of which shaped near misses. Hospital leaders should recognize both forms of understaffing when making staffing decisions, particularly during times of crisis.

The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: the QUMwatch study.

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Adie K, Fois RA, McLachlan AJ, et al. Br J Clin Pharmacol. 2021;87:4809-4822.

Medication errors are a common cause of patient harm. This study analyzed medication incident (MI) reports from thirty community pharmacies in Australia. Most errors occurred during the prescribing stage and were the result of interrelated causes such as poor communication and not following procedures/guidelines. Further research into these causes could reduce medication errors in the community.

Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen-year period.

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Le Cornu E, Murray S, Brown EJ, et al. J Med Radiat Sci. 2021;68:356-363.

Use of health information technology (HIT) can improve care but also lead to unexpected patient harm. In this analysis of incidents and near misses in radiation oncology, a major change in the use of the electronic health record (EHR) led to an increase in reported incidents and near misses. Leaders and HIT professionals should be aware of potential issues and develop a plan to minimize risk prior to major departmental changed including EHR changes.

A comprehensive departmental care review model: requirements, structure, and flow.

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Nestler DM, Laack TA, Scanlan-Hanson L, et al. Jt Comm J Qual Patient Saf. 2021;47:503-509.

Peer review can provide clinicians an opportunity to learn from failure, but the process has yet to be standardized. This article describes the development and implementation of an evidence-based, structured, reproducible care review system at one emergency department affiliated with an academic hospital. The authors outline the care review process, which includes direct care staff feedback; single provider and peer review; structured case rating; systems analysis; loop closure; practice and education output; and consideration of psychological safety.

Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United States operating rooms.

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Weprin SA, Meyer D, Li R, et al. Patient Saf Surg. 2021;15:14.

A retained surgical sharp (RSS) is a never event. Operating room (OR) team members, including surgeons, anesthesiologists, and nurses, were surveyed regarding their experiences with actual and near-miss sharps (NMS). While nearly all team members reported experiencing at least one RSS or NMS in the past year, responses to other survey items varied by professional group. Surgeons were less likely to perceive that a sharp had been lost as compared to other OR team members, indicating a potential under-report bias. Improved communication between team members may increase identification, and therefore reporting, of RSS and NMS, to prevent similar incidents in the future.

Quality of life after maternal near miss: a systematic review.

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Rosen IEW, Shiekh RM, Mchome B, et al. Acta Obstet Gynecol Scand. 2021;100:704-714.

Improving maternal safety is an ongoing patient safety priority. This systematic review concluded that maternal near miss events are negatively associated with various aspects of quality of life. Women exposed to maternal near miss events were more likely to have overall lower quality of life, poorer mental and social health, and suffer negative economic consequences.

An Inadvertent Bolus of Norepinephrine.

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May 26, 2021

A 64-year-old woman was admitted to the hospital for aortic valve replacement and aortic aneurysm repair. Following surgery, she became hypotensive and was given intravenous fluid boluses and vasopressor support with norepinephrine. On postoperative day 2, a fluid bolus was ordered; however, the fluid bag was attached to the IV line that had the vasopressor at a Y-site and the bolus was initiated.

Just culture: the foundation of staff safety in the perioperative environment.

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Fencl JL, Willoughby C, Jackson K. AORN J. 2021;113:329-336.

A just culture balances organizational and individual accountability when a medical error occurs. In a just culture, staff are more likely to report potential patient safety concerns. This commentary defines just culture, describes the critical elements, and provides tools and resources to implement a just culture in the perioperative setting that may increase staff and patient safety.

Medication incident recovery and prevention utilising an Australian community pharmacy incident reporting system: the QUMwatch study.

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Adie K, Fois RA, McLachlan AJ, et al. Eur J Clin Pharmacol. 2021;77:1381-1395.

Community pharmacists play an important role in patient safety. In this longitudinal study, community pharmacists reported 1,013 medication incidents, mainly at the prescribing and dispensing stages. Recommended prevention strategies included improved patient safety culture, adherence to organizational policies and procedures, and healthcare provider education.

Nurse's Achilles Heel: using big data to determine workload factors that impact near misses.

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Campbell AA, Harlan T, Campbell M, et al. J Nurs Scholarsh. 2021;53:333-342.

Using electronic health records, call light systems, and bar-code medication administration systems, this study examined the impact of six specific workload variables on nurses’ medication administration errors. At least one of the six variables was significantly associated with the occurrence or nonoccurrence of a near miss medication error in the majority of nurses. Because the specific variable(s) differed for each individual nurse, interventions addressing medication administration errors should be tailored to individual nurse risk factors.

How communication "failed" or "saved the day": counterfactual accounts of medical errors.

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Street RL, Petrocelli JV, Amroze A, et al. J Patient Exp. 2020;7:1247-1254.

Patient and family engagement play a critical role in patient safety. This study found that patient and family members perceived that information inadequacy, not listening, and dismissive behavior contributed to communication breakdowns that led to medical errors or close calls. These findings underline the critical role of patient and family engagement to prevent errors and improve care delivery.

Missing the near miss: recognizing valuable learning opportunities in radiation oncology.

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Kundu P, Jung OS, Valle LF, et al. Pract Radiat Oncol. 2021;11:e256-e262.

Underreporting of ‘near misses’ can impede efforts to improve healthcare quality and patient safety. Based on hypothetical scenarios involving a patient with a cardiac pacemaker undergoing radiation treatment, this study surveyed healthcare staff about their evaluation of the events and their willingness to report based on their evaluation of the hypothetical scenarios. Findings suggest that cognitive biases can influence willingness to report based on how near miss events are perceived.

Registration errors among patients receiving blood transfusions: a national analysis from 2008 to 2017.

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Vijenthira S, Armali C, Downie H, et al. Vox Sang. 2021;116:225-233.

Transfusion errors can have serious consequences. This retrospective analysis used a Canadian national database to characterize patient registration-related errors in the blood transfusion process. Findings indicate that registration errors most commonly occur in outpatient areas and emergency departments and can lead to delays in transfusion.

Dispensing Errors.

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Phipps D, Ashour A, Riste L, et al. The Pharmaceutical Journal. 2020;305(7943, 7944). November 10, December 1, 2020.

Dispensing mistakes are a common contributor to preventable adverse events in community pharmacies. Part 1 of this two-part series discusses factors that contribute to dispensing errors and summarizes methods for managing risks stemming from missteps. Part 2 focuses on preventing situations that enable errors and the role pharmacists have in minimizing dispensing errors in daily practice.

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