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Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis.

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Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21:139.

Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.

Intersystem medical error discovery: a document analysis of ethical guidelines.

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Duffy B, Miller J, Vitous CA, et al. J Patient Saf. 2021;17:e1765-e1773.

Healthcare providers are increasingly disclosing their errors to patients. This review summarizes available guidance for how and when to report other providers’ errors, particularly those outside their own facility or system. Guidelines tended to be ambiguous and restricted to incompetence.

Integrating principles of safety culture and just culture into nursing homes: lessons from the pandemic.

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Gaur S, Kumar R, Gillespie SM, et al. J Am Med Dir Assoc. 2021;23:241-246.

A culture of safety in nursing homes has been linked to improved resident care. The authors describe how the alignment of regulatory oversight and surveys could integrate with just culture to improve resident safety.

Program access, depressive symptoms, and medical errors among resident physicians with disability.

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Meeks LM, Pereira-Lima K, Frank E, et al. JAMA Netw Open. 2021;4:e2141511.

This survey estimates the prevalence of disability among medical residents to be 7.5%. Findings suggest an association between lack of accessibility through accommodations and increased risk for depression and self-reported medical errors during training.

Safety, Equity and Engagement in Maternity Services.

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Newcastle upon Tyne, UK: Care Quality Commission; September 2021.

The safety of maternity care is threatened by inequity. This report analyzes a set of United Kingdom investigation reports to identify issues affecting maternity care to determine their prevalence elsewhere in the system. Problems identified include poor leadership and teamwork, as well as learning and cross-service collaboration.

Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative.

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Li L, Foer D, Hallisey RK, et al. J Patient Saf. 2022;18:e108-e114.

Despite the introduction of computerized provider order entry into electronic health records, providers still frequently use free-text fields to communicate important information which introduces a patient safety risk. One healthcare system searched allergy-related free-text fields, identifying more than 242,000 entries. Approximately 131,000 were manually or automatically remediated (e.g., “latex from back brace” and “gloves” were coded “latex-natural rubber”).

National Healthcare Quality and Disparities Reports.

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Rockville, MD: Agency for Healthcare Research and Quality.

In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. This 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.

Next of kin involvement in regulatory investigations of adverse events that caused patient death: a process evaluation.

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Wiig S, Haraldseid-Driftland C, Tvete Zachrisen R, et al. J Patient Saf. 2021;17(8):e1707-e1718.

Families and next of kin are important partners in patient safety. In two Norwegian counties, next of kin who had lost a family member due to an adverse event participated in in-person meetings with inspectors as part of the regulatory investigation. This study explored the experiences and perspectives of the next of kin (Part 1) and regulatory inspectors (Part 2) involved in this new approach to next-of-kin involvement in regulatory investigations. Despite being an emotionally challenging process, next of kin viewed participation in the regulatory investigation as a positive experience and believed that their contributions improved the investigation process.

The impact of health information management professionals on patient safety: a systematic review.

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Kemp T, Butler‐Henderson K, Allen P, et al. Health Info Libr J. 2021;38:248-258.

This review focused on the impact of the Health Information Management (HIM) profession on patient safety as it relates to health information documentation. Key themes identified were data quality, information governance, corporate governance, skills, and knowledge required for HIM professionals.

We Can’t Do This Alone! The Role That Patients, Family Members, and the General Public Play in Advancing Patient Safety.

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Patient Safety Movement Foundation. January 25, 2022.

Successful patient safety improvements engage individuals across the continuum of care and administrative processes, including patients as advocates for change. This webinar highlighted the role of the patient in influencing legislation designed to affect systems of care to ensure safe practice.

Complaints to the Parliamentary and Health Service Ombudsman.

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London, UK: Parliamentary and Health Service Ombudsman.

The National Health Service broadly reports the results of system-level analyses and investigations into trust-specific failures. This publication series provides information about complaints submitted to trusts to track complaints received and responded to, identify common themes, and uncover recurring problems in an effort to enable organizations to improve processes for managing complaints.

Harnessing event report data to identify diagnostic error during the COVID-19 pandemic.

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Shen L, Levie A, Singh H, et al. Jt Comm J Qual Patient Saf. 2022;48:71-80.

The COVID-19 pandemic has exacerbated existing challenges associated with diagnostic error. This study used natural language processing to identify and categorize diagnostic errors occurring during the pandemic. The study compared a review of all patient safety reports explicitly mentioning COVID-19, and using natural language processing, identified additional safety reports involving COVID-19 diagnostic errors and delays. This innovative approach may be useful for organizations wanting to identify emerging risks, including safety concerns related to COVID-19.

Real-world virtual patient simulation to improve diagnostic performance through deliberate practice: a prospective quasi-experimental study.

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Kotwal S, Fanai M, Fu W, et al. Diagnosis (Berl). 2021;8:489-496.

Previous studies have used virtual patient cases to help trainees and practicing physicians improve diagnostic accuracy. Using virtual patients, this study found that brief lectures combined with 9 hours of supervised deliberate practice improved the ability of medical interns to correctly diagnose dizziness.

Input for the TeamSTEPPS Curriculum Updates.

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Rockville MD, Agency for Healthcare Quality and Research. December 7, 2021.

The TeamSTEPPS program is an established approach for improving teamwork and communication in health care. This announcement calls for feedback from healthcare teams and team members on how to update the current TeamSTEPPS training curriculum.

Mitigating patient and consumer safety risks when using conversational assistants for medical information: exploratory mixed methods experiment.

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Bickmore TW, Olafsson S, O'Leary TK. J Med Internet Res. 2021;23:e30704.

Patients and families increasingly access mobile apps, conversational assistants, and the internet to find information about health conditions or medications. In a follow up to an earlier study, researchers evaluated two approaches to determine the likelihood that patients would act upon the information received from conversational assistants.

An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting.

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Kuznetsova M, Frits ML, Dulgarian S, et al. JAMIA Open. 2021;4:ooab096.

Dashboards can be used to synthesize data and visualize patient safety indicators and metrics to facilitate decision-making. The authors reviewed design features of patient safety dashboards from 10 hospitals and discuss the variation in the use of performance indicators, style, and timeframe for displayed metrics. The authors suggest that future research explore how specific design elements contribute to usability, and which approaches are associated with improved outcomes.

Impact of state nurse practitioner regulations on potentially inappropriate medication prescribing between physicians and nurse practitioners: a national study in the United States.

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Tzeng H-M, Raji MA, Chou L-N, et al. J Nurs Care Qual. 2021;37:6-13.

Potentially inappropriate medications (PIMs) for older adults carry a high risk of adverse drug events. Using a sample of Medicare beneficiaries from 2015 to 2018, researchers assessed the impact of state scope of practice regulations for nurse practitioners (NPs) on PIM prescribing patterns compared to primary care physicians. Findings indicate that the PIM prescribing rate is lower in states with full NP practice and lower among NPs than among physicians.

National Patient Safety Board Advocacy Coalition.

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EQT Plaza, 625 Liberty Ave, Ste. 2500, Pittsburgh, PA 15222.

Centralized reporting and analysis of adverse events in health care is a safety improvement model from the aviation industry that has yet to be enabled in health care. This organization shares information to support the establishment of a national body charged with the collection and monitoring of adverse event data to inform research and recommendations for medical error reduction.

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.

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