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Seidl E, Seidl O. J Healthc Risk Manag. 2021;41(2):9-17.
Diagnostic safety is a patient safety priority across all medical specialties. Over a five-year period, researchers found that 15% of patients referred for psychosomatic consultations at one university hospital were misdiagnosed. Misdiagnosis was primarily attributed to availability bias or other biases. Semi-structured interviews with referring physicians highlight the contributing role of physician attitudes and unusual clinical features.
Skoogh A, Hall-Lord ML, Bååth C, et al. BMC Health Serv Res. 2021;21(1):1093.
Improving maternal safety is a priority patient safety issue. Using the Global Trigger Tool, researchers found that nearly three-quarters of adverse events in one labor ward in a Swedish hospital were preventable. Common events included lacerations and anesthesia-related events and often resulted in a prolonged hospital stay.

Manchester, UK: Parliamentary and Health Service Ombudsman; October 2021.

This report examines a premature infant death associated with failings of antibiotic administration, deterioration recognition and action on family concerns both during treatment and post-incident. The report issues a series of recommendations building on standard remediation guidance in the United Kingdom.

The Daisy Foundation and Institute for Healthcare Improvement.

Nurses have a fundamental role in safe care delivery by fostering a healthy work environment. This award recognizes nurses that exhibit compassion, patient and family centeredness, and a commitment to workplace safety. The award will be presented at annual IHI Patient Safety Congress. Award nominations are due December 3, 2021.

ISMP Medication Safety Alert! Acute care edition. October 21, 2021;26(21):1-3.

Shortcuts in automated data entry behaviors have potential to result in errors. This article discusses search term length requirements for automated dispensing cabinets and the importance of doing a proactive failure analysis prior to implementing any system conditions to minimize unintended consequences of the rules that could detract from safety.
Rosenthal CM, Parker DM, Thompson LA. JAMA Pediatr. 2021;Epub Oct 19.
The care of child abuse victims is affected by resource, racial and infrastructure challenges. This commentary describes how the systemic weaknesses catalyzed by poor data collection approaches contribute to misdiagnosis and suggests that successes be mined to minimize the proliferation of continued disparities in this patient population.
California Hospital Patient Safety Organization. Sacramento, CA; 2021.
Patient Safety Organizations (PSOs) capture and analyze local data to inform learning among their members. This report highlights 2020 trends, activities, and outcomes of initiatives at a 21-state PSO. Sections of the report include high-level review of reported medication events, safe table data analysis, and strategies to improve data quality.
Alanazi FK, Sim J, Lapkin S. Nurs Open. 2021;Epub Sep 20.
Nurse attitudes towards patient safety culture have shown to impact missed nursing care, iatrogenic harm, and other adverse events. This review synthesizes research on nurses’ safety attitudes and subsequent impact on patient outcomes. While most data on adverse events was self-reported, nurses indicated an improved safety culture resulted in fewer reported adverse events. Nurse managers can play an important role in improving patient safety culture and outcomes in their hospital units.
Bell SK, Bourgeois FC, DesRoches CM, et al. BMJ Qual Saf. 2021;Epub Oct 16.
Engaging patients and families in their own care can improve outcomes, safety, and satisfaction. This study brought patients, families, clinicians and experts together to identify patient-reported diagnostic process-related breakdowns. The group identified 7 categories, 40 subcategories, 19 contributing factors and 11 patient-reported impacts. Breakdowns were identified in each step of the diagnostic process.
Paulin J, Kurola J, Koivisto M, et al. BMC Emerg Med. 2021;21(1):115.
Emergency medical services (EMS) personnel are in the unique position of providing medical care outside of a healthcare facility. This prospective cohort study conducted in Finland explored the outcomes of patients who were treated by EMS personnel without going to the ED. Findings indicate that 80% of patients treated by EMS did not have any re-contact with the healthcare system (e.g., re-contacted EMS, went to the ED, were hospitalized), suggesting that EMS management of these patients is relatively safe.

The relationship between burnout among healthcare workers and poor patient safety outcomes has been well-documented. The COVID-19 pandemic exacerbated burnout risk due to increased emotional exhaustion, stress, and fatigue. In response to effects of pandemic, the University of Minnesota developed the MN Resilience Program. This innovative program leverages the “Battle Buddy” system used in the US Army, and resilience principles to support the psychological and emotional well-being among healthcare workers and to connect healthcare workers to peer support.

Understanding the ways in which human factors, such as non-technical skills, influence individual and team performance can ultimately improve patient safety, particularly in high-intensity settings such as operating rooms. The Observation of Non-technical Skills and Teamwork (ONSet) program, created by the Cambridge University Hospitals, uses observation and feedback from Human Factors Champions to evaluate the impact of human factors education in operating rooms.

Deprescribing is an intervention used to reduce the risk of adverse drug events (ADEs) that can result from polypharmacy. It is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use.

A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution.

Bjørn B, Anhøj J, Østergaard M, et al. J Patient Saf. 2021;17(1):e593-e598.
Trigger tools are used as signals to detect potential adverse events. Using the Institute for Healthcare Improvement Global Trigger Tool (GTT), one patient safety review team was unable to reproduce harm rates in a test-retest reliability study, suggesting the GTT may not be a reliable measure of harm over time. The team recommends additional test-retest studies in other hospitals.
Brühwiler LD, Niederhauser A, Fischer S, et al. BMJ Open. 2021;11(10):e054364.
Polypharmacy and potentially inappropriate medications continue to pose health risks in older adults. Using a Delphi approach, experts identified 85 minimal requirements for safe medication prescribing in nursing homes. The five key topics recommend structured, regular review and monitoring, interprofessional collaboration, and involving the resident.