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Missed care is a subset of the category known as “error of omission.” It refers to care that is delayed, partially completed, or not completed at all. Missed care can result in lower safety culture ratings, increases in adverse events such as pressure injuries, and higher rates of postoperative mortality.

Misdiagnosis in the context of patient safety is an erroneous or delayed diagnosis and has the potential to cause patient harm. The term is frequently used interchangeably with "diagnostic error". Misdiagnoses can potentially prevent or delay appropriate treatment or result in unnecessary or harmful treatment, which can lead to physical, psychological, or financial harm to patients. Misdiagnosis can be caused by cognitive biases in clinicians or underlying systems-level issues in health care.

Mindfulness reflects an organizational and/or team ability to motivate and enculturate abilities and opportunities to create awareness of the myriad of facets affecting detection of potential or emergent situations before they unfold to prevent escalation into failure and provide understanding to coordinate a response during an incident. This can be accomplished through initiatives that involve multidisciplinary work and develop teams and relationships. The concept aligns with the core components of high reliability as defined by Weick/Sutcliff.

Related terms: high reliability organizations; situational awareness

The Medication Administration Record (MAR) is a legal and permanent documentation of a patient’s medications administered, typically by a nurse in an acute or sub-acute setting. Use of technology (such as bar-coded medication administration) and standardized procedures (such as two-person verification or application of the “rights” of medication administration are included in the medication administration process to improve patient safety.

Learning systems build functions, networks, and processes to use data, information, evidence, and knowledge to implement change and, ultimately, to sustain improvements. Learning systems focus both on internal improvement and information sharing, as well as external distribution of data and knowledge using technology to generate improvement in the larger environment in which the organization functions. Learning systems nurture a culture that enables information sharing and improved collective awareness across the spectrum of the healthcare system.

Lean principles include standardized work, value stream, workflow, reducing waste, and efficiency with a focus on the customer experience.  Application of Lean principles to healthcare settings increases patient safety and ensures that the patient’s healthcare experience is effective and of high quality. Researchers have used Lean methodology to improve processes related to chemotherapy preparation, surgical instrument sterilization, and medication administration.

Inattentional blindness is a cognition concept exploring why individuals in an intense or complex situation can miss an important event or data point because competing attentional tasks divide their focus. Individuals experiencing inattentional blindness unknowingly orient themselves toward, and process information from, only one part of their environment, while excluding others which can contribute to task omissions and missed signals, such as incorrect medication administration.

Human factors are the strengths and constraints in the design of interactive systems and actions involving people, tools and technology, and work environments to ensure their safety, reliability, and effectiveness. Ergonomics is a related term, which is the study of the interplay between human factors, technologies, and work environments.

Related term: human factors engineering

Cox C, Fritz Z. BMJ. 2022;377:e066720.

As more patients are gaining access to their electronic health records, including clinician notes, the language clinicians use can shape how patients feel about their health and healthcare provider. This commentary describes how some words and phrases routinely used in provider notes, such as “deny” or “non-compliant”, may inadvertently build distrust with the patient. The authors recommend medical students and providers reconsider their language to establish more trusting relationships with their patients.
Lee EH, Pitts S, Pignataro S, et al. Clin Teach. 2022;19:71-78.
The inherent power imbalance between supervisors and new clinicians may inhibit new clinicians from asking questions or reporting mistakes. This lack of psychological safety can result in patient harm and restrict learning. This article provides strategies for healthcare educators and leaders to model and guide a safer organization. Three phases of the supervisor-learner relationship, along with suggested prompts, are provided.
Sederstrom N, Lasege T. Hastings Cent Rep. 2022;52:s24-s29.
Racial bias and systemic racism in healthcare are increasingly seen as critical patient safety issues. This commentary discusses the relationship between medical ethics and racism in healthcare institutions, using examples such as racial biases in clinical tools and algorithms, the effect of racial bias on diagnosis and diagnostic error, and how excess disease burden can be viewed as proxy for racism.

Chicago, IL: Harpo Productions, Smithsonian Channel: May 2022.

The COVID-19 pandemic revealed the impact of racial disparities and inequities on patient safety for patients of color. This film shares stories of families whose care was unsafe. The cases discussed highlight how missed and dismissed COVID symptoms and inattention to patient and family concerns due to bias reduces patient safety.
Brady KJS, Barlam TF, Trockel MT, et al. Jt Comm J Qual Patient Saf. 2022;48:287-297.
Inappropriate prescribing of antibiotics to treat viral illnesses is an ongoing patient safety threat. This study examined the association between clinician depression, anxiety, and burnout and inappropriate prescribing of antibiotics for acute respiratory tract infections (RTIs) in outpatient care. Depression and anxiety, but not burnout, were associated with increased adjusted odds of inappropriate prescribing for RTIs.
Braun EJ, Singh S, Penlesky AC, et al. BMJ Qual Saf. 2022;Epub Apr 15.
Early warning systems (EWS) use patient data from the electronic health record to alert clinicians to potential patient deterioration. Twelve months after a new EWS was implemented in one hospital, nurses were interviewed to gather their perspectives on the program experience, utility, and implementation. Six themes emerged: timeliness, lack of accuracy, workflow interruptions, actionability of alerts, underappreciation of core nursing skills, and opportunity cost.
Buhlmann M, Ewens B, Rashidi A. J Adv Nurs. 2022;Epub Apr 22.
The term “second victims” describes clinicians who experience emotional or physical distress following involvement in an adverse event. Nurses and midwives were interviewed about “moving on” from the impact of a critical incident. Five main themes were identified: Initial emotional and physical response, the aftermath, long-lasting repercussions, workplace support, and moving on. Lack of organizational support exacerbated the nurses’ and midwives’ responses.
Carfora L, Foley CM, Hagi-Diakou P, et al. PLoS ONE. 2022;17:e0267030.
Patients are frequently asked to complete patient-reported outcome measures (PROM), or standardized questionnaires, to assess general quality of life, screen for specific conditions or risk factors, and perspectives on their health. This review identified 14 studies related to patient perspectives regarding PROMs. Three themes emerged: patient preferences regarding PROMs, patient perceived benefits, and barriers to patient engagement with PROMs.
Lim L, Zimring CM, DuBose JR, et al. HERD. 2022;Epub Apr 5.
Social distancing policies implemented during the COVID-19 pandemic challenged healthcare system leaders and providers to balance infection prevention strategies and providing collaborative, team-based patient care. In this article, four primary care clinics made changes to the clinic design, operational protocols, and usage of spaces. Negative impacts of these changes, such as fewer opportunities for collaboration, communication, and coordination, were observed.
MacLeod JB, D’Souza K, Aguiar C, et al. J Cardiothorac Surg. 2022;17:69.
Post-operative complications can lead to increased length of hospital stay, cost, and resource utilization. This retrospective study compared “fast track” patients (patients extubated and transferred from ICU to a step-down unit the same day as their procedure) and patients who were not fast tracked. Results showed fast track pathways led to a reduction in ICU and overall hospital length of stay and similar post-operative outcomes.
Morsø L, Birkeland S, Walløe S, et al. Jt Comm J Qual Patient Saf. 2022;48:271-279.
Patient complaints can provide insights into safety threats and system weaknesses. This study used the healthcare complaints analysis tool (HCAT) to identify and categorize safety problems in emergency care. Most problems arose during examination/diagnosis and frequently resulted in diagnostic errors or errors of omission.