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Adams-McGavin RC, Jung JJ, van Dalen ASHM, et al. Ann Surg. 2021;274(1):114-119.
Resilience is the process of identifying and overcoming unexpected adverse events. By reviewing video, audio, and patient physiologic data recorded during 24 laparoscopic surgeries, researchers were able to identify safety threats and resilience supports used to overcome them. Of the six category codes, (person, task, tools and technology, physical environment, organization, and external environment) most safety threats and supports were in the person category.
Chegini Z, Arab‐Zozani M, Shariful Islam SM, et al. Nurs Forum. 2021;Epub Aug 3.
Efforts to engage patients in patient safety have increased but are not always successful. This review identified facilitators and barriers to patient engagement from patient and healthcare provider perspectives. Barriers included both patient and provider unwillingness; facilitators included encouraging and sharing information with patients.
Gould D, Purssell E, Jeanes A, et al. BMJ Qual Saf. 2021;Epub Jul 16.
The “My Five Moments for Hand Hygiene” framework is promoted by the World Health Organization to decrease healthcare-associated infections (HAIs). This article identifies five limitations of the Five Moments and proposes solutions to improve hand hygiene, including capitalizing on infection control measures brought about by the COVID-19 pandemic.
Hoyle JD, Ekblad G, Woodwyk A, et al. Prehosp Emerg Care. 2021:1-8.
Inaccurate assessment of pediatric patient weight can lead to medication dosing errors. In simulated pediatric scenarios, pre-hospital emergency medical services (EMS) crews obtained patient weight using one or more of three methods: asking parent, using patient age, and Broselow-Luten Tape (BLT). BLT was the most frequent method used and patient age resulted in the most frequent dosing errors. Systems-based solutions are presented.
Metersky ML, Eldridge N, Wang Y, et al. J Patient Saf. 2021;Epub Aug 14.
The July Effect is a belief that the quality of care delivered in academic medical centers decreases during July and August due to the arrival of new trainees. Using data from the Medicare Patient Safety Monitoring System, this retrospective cohort, including over 185,000 hospital admissions from 2010 to 2017, found that patients admitted to teaching hospitals in July and August did not experience higher rates of adverse events compared to patients admitted to non-teaching hospitals.
Monazam Tabrizi N, Masri F. BMJ Open. 2021;11(8):e048036.
In this qualitative study, researchers interviewed 40 clinicians in high- and low-performing hospitals to better understand the barriers to effective organizational learning from medical errors. Findings from these interviews suggest that the primary barriers to active learning stem from social issues post-reporting – e.g., lack of trust or proactive engagement from management. The authors highlight the importance of fostering an organizational culture that encourages cooperation and collaboration between management and clinicians.
Paradissis C, Cottrell N, Coombes ID, et al. Ther Adv Drug Saf. 2021;12:204209862110274.
Adverse drug events are a common source of harm in both inpatient and ambulatory patients. This narrative review of 75 studies concluded that cardiovascular medications are a leading cause of medication harm across different clinical settings, and that older adults are at increased risk. Medications to treat high blood pressure and arrhythmias were the most common cause of medication harm.
Prabhu V, Mikhly M, Chung R, et al. Am J Med Qual. 2021;Epub Jun 11.
Encouraging adverse event reporting among clinicians, including medical trainees, is essential to improving patient safety. This hospital implemented a multi-pronged intervention – using a combination of branding, education and outreach, and feedback – to increase patient safety event reporting by house staff. The intervention led to increased event reporting in the short- and long-term.
Urquhart A, Yardley S, Thomas E, et al. J R Soc Med. 2021;Epub Aug 4.
This mixed-methods study analyzed patient safety incident reports between 2005-2015 to characterize the most frequently reported incidents resulting in severe harm or death in acute medical units. Of the 377 included reports, diagnostic errors, medication-related errors, and failure to monitor patient incidents were most common. Patients were at highest risk during handoffs and transitions of care. Lack of active decision-making during admission and communication failures were the most common contributors to incidents.
Wei W, Coffey W, Adeola M, et al. Am J Health Syst Pharm. 2021;Epub Jul 15.
Smart pumps can improve medication safety, but barriers such as workarounds and alert fatigue can limit their effectiveness. After implementing smart pumps with an electronic health record (EHR) system, this community hospital saw increased drug library compliance and fewer infusions generating alerts.

Washington, DC: Department of Veterans Affairs, Office of Inspector General.  July 29, 2021. Report No. 21-00657-197.

Care coordination effectiveness is tested by time, hierarchy, and practice silos. This report examines allegations affecting medication access enabled by poor communication, workforce absences, and the built environment challenges. While care coordination challenges in this case were unsubstantiated, the report highlights lack of clinical review and inaccurate analysis of patient death as concerns.

Szalavitz M. Wired Magazine. August 11, 2021. 

The opioid epidemic has contributed to uncertainties for pain management patients that result in harm. This article discusses how an endometriosis patient was unable to get prescriptions to manage her pain due to misinformation generated through screening tools designed to identify opioid misuse and inform prescribing decisions.

Fourth Report of Session 2021–22. House of Commons Health Committee. London, England: The Stationery Office; July 6, 2021. Publication HC 19. 

High-profile failures motivate examination and change of existing services. This report builds on maternity care failures in National Health Service trusts to recommend needed changes in learning from failure to effectively support clinicians providing maternity care, provide patient-centered care to mothers and babies, and learn from untoward incidents to enhance care safety.

Kahneman D, Sibony O, Sunstein CR. London, UK: William Collins; 2021. ISBN 9780008472566.

Lack of agreement, or noise, in leadership and clinical decision making can contribute to poor care. This book discusses influences on human judgement that contribute to disagreement when different people receive the same information and how to prevent its negative impact. It describes the influence of noise in a variety of sectors including medicine with specific emphasis on diagnosis.
Fatemi Y, Coffin SE. Diagnosis (Berl). 2021;8(4):525-531.
Using case studies, this commentary describes how availability bias, diagnostic momentum, and premature closure resulted in delayed diagnosis for three pediatric patients first diagnosed with COVID-19. The authors highlight cognitive and systems factors that influenced this diagnostic error.
Vaghani V, Wei L, Mushtaq U, et al. J Am Med Inform Assoc. 2021;28(10):2202-2211.
Based on the SaferDx and SPADE frameworks, researchers applied a symptom-disease pair-based electronic trigger (e-trigger) to identify patients hospitalized for stroke who had been previously discharged from the emergency department with a diagnosis of headache or dizziness in the preceding 30 days. Analyses show that the e-trigger identified missed diagnoses of stroke with a modest positive predictive value.
Organization: Duke University Health System Patient Safety Center
Event Description: This one or two year long series covers the science of well-being and the practical tools and strategies practitioners can use to emotionally support themselves and their team, department, unit, or organization.
Event Location: Online
Date: Various Dates
Event Fee: Fee Associated
CE or CME Offered?