Soncrant C, Mills PD, Pendley Louis RP, et al. J Patient Saf. 2021;17:e821-e828.
Using data from the Veterans Health Administration National Center for Patient Safety, this retrospective study found that suicide and opioid overdose are the most serious healthcare-related adverse events affecting homeless veterans. Identified root causes include issues related to risk assessment for suicidal or overdose behaviors as well as poor interdisciplinary communication and coordination of care.
Warm EJ, Ahmad Y, Kinnear B, et al. Acad Med. 2021;96:1268-1275.
Technical and procedural skills are an important emphasis of medical training. This article briefly summarizes the “as low as reasonably achievable” (ALARA) approach, which was developed for the nuclear industry and has been used in radiology. The authors outline how ALARA risk standards can be adapted by training program directors to measure procedural competency and assess and reduce bedside procedural risks.
Fernandez Branson C, Williams M, Chan TM, et al. BMJ Qual Saf. 2021;30:1002-1009.
Receiving feedback from colleagues may improve clinicians’ diagnostic reasoning skills. By building on existing models such as Safer Dx, and collaborating with professionals outside of the healthcare field, researchers developed the Diagnosis Learning Cycle, a model intended to improve diagnosis through peer feedback.
Mackenhauer J, Winsløv J-H, Holmskov J, et al. Crisis. 2021;43:307-314.
Prior research has found that patients who die by suicide often had recent contact with the healthcare setting. Based on a multi-year chart review at one institution, the authors concluded that suicide risk assessment and documentation in the heath record to be insufficient. The authors outline quality improvement recommendations focused on improving documentation, suicide assessment and intervention training, and improving communications with families, caregivers, and other health care providers.
Hospital-acquired pressure injuries (HAPI) can lead to increase costs and length of stay. Through root cause analysis, this geriatric rehabilitation hospital identified factors that contributed to the development of HAPI in its facility. Recommendations for improvement targeted both system- and human-level factors.
Langevin M, Ward N, Fitzgibbons C, et al. Simul Healthc. 2022;17:e51-e58.
Prior research has found that simulation-based event analysis (SBEA) can identify novel sources of error as well as generate creative strategies for error prevention. In this study, researchers found that simulation can optimize SBEA-generated recommendations and that it provides opportunity to test the intervention in real-life settings before widespread implementation.
Harm from opioids is a widely recognized patient safety issue, and potential harm associated with short-term use is a growing area of concern. This analysis of a previously opioid-free surgical population identified a high rate of potential opioid-related adverse drug events (ORADEs); risk was strongly associated with route and duration of post-operative opioid administration. The presence of an ORADE was associated with longer postoperative length of stay, higher hospitalization costs, lower odds of discharge home, and higher odds of death.
Tzeng H-M, Jansen LS, Okpalauwaekwe U, et al. J Nurs Care Qual. 2021;36:327-332.
Patient falls are an ongoing patient safety concern, yet mitigating falls among inpatients remains challenging. This article describes one nursing home’s experience adapting the Fall TIPS program for use in their patient population. The program, which emphasizes tailored fall-prevention and patient-family engagement, resulted in a decrease in the rate of falls and injuries.
Dykes PC, Lowenthal G, Faris A, et al. J Patient Saf. 2021;17:56-62.
Failure to rescue – the lack of adequate response to patient deterioration – has been associated with adverse patient outcomes, particularly in acute care settings. This article describes two health systems’ efforts to implement in-hospital Clinical Monitoring System Technology (CMST) which positively impacted failure-to-rescue events. The authors identified barriers and facilitators to CMST use, which informed the development of an implementation toolkit addressing readiness, implementation, patient/family introduction, champions, and troubleshooting.
Kjaergaard-Andersen G, Ibsgaard P, Paltved C, et al. Int J Health Care Qual. 2021;33:mzaa148.
Simulation training is used by hospitals to improve patient care. This study describes the experience of one Danish hospital shifting from simulation training at external centers to in situ training. The shift to in situ training identified several latent safety threats (e.g., equipment access, lack of closed-loop communication, out-of-date checklists) and these findings led to practice changes.
Lee M, Lee N-J, Seo H-J, et al. West J Nurs Res. 2021;43:972-983.
Patients and families are essential partners in identifying and preventing safety events. In this systematic review, the authors found that information-based interventions (e.g., videos, offline classes) promoting patient and family engagement in patient safety were mostly effective. The effectiveness of interventions involving both information and involvement (e.g., use of decision aids to determine care plan) strategies was inconsistent.
Chen A, Wolpaw BJ, Vande Vusse LK, et al. Acad Med. 2021;96:75-82.
Quality improvement and patient safety (QIPS) training is increasingly being incorporated into formal medical education. This article describes an integrated framework for QIPS training for internal medicine residents focused on four areas: (1) culture of safety, (2) strategies for investigating events and tracking improvements, (3) reporting and presenting events, and (4) improvement work. This specialty-agnostic framework allows for integration across graduate medical education (GME) specialties and can serve as a model for other institutions.
Britton CR, Hayman G, Stroud N. J Perioper Pract. 2021;31:44-50.
The COVID-19 pandemic has highlighted the crucial role that team and human factors play in healthcare delivery. This article describes the impact of a human factors education and training program focused on non-technical skills and teamwork (the ONSeT project) – on operating room teams during the pandemic. Results indicate that the project improved team functioning and team leader responsiveness.
Sigal A, Shah A, Onderdonk A, et al. Pain Med. 2021;22:499-505.
Reducing opioid-related overdoses and deaths is a national patient safety priority. This study analyzed the impact of implementing three quality improvement interventions on the opioid prescribing practices of emergency providers at one hospital – the implementation of a prescription drug monitoring program, clinical education on alternatives to opioids, and electronic health record (EHR) process changes. Findings indicate that these three approaches can decrease the amount of opioids prescribed in an acute ED setting.
Koike D, Nomura Y, Nagai M, et al. Int J Qual Health Care. 2020;32:522-530.
Nontechnical skills are gaining interest as one way to enhance surgical team performance and patient safety. In this single-center study, the authors found that a perioperative bundle that introduced nontechnical skills to the surgical team was effective in reducing operative time.
Opioid misuse is an urgent patient safety issue, including postsurgical opioid misuse among pediatric patients. Based on the systematic review, a multidisciplinary group of health care and opioid stewardship experts proposes evidence-based opioid prescribing guidelines for children who need surgery. Endorsed guideline statements highlight three primary themes for perioperative pain management in children: (1) health care professionals must recognize the risks of pediatric opioid misuse, (2) use non-opioid pain relief, and (3) pre- and post-operative education for patients and families regarding pain management and safe opioid use.
Ash JS, Corby S, Mohan V, et al. J Amer Med Inform Assoc. 2021;28:294-302.
The use of medical scribes for electronic health record (EHR) documentation is one strategy to shift the burden of documentation away from clinicians. Using interviews and direct observations, the authors explored the effects of scribes on patient safety. Participants did not perceive significant patient safety risks with scribes and highlighted the positive effects scribes have on documentation efficiency, quality, and safety.
Meyer AND, Upadhyay DK, Collins CA, et al. Jt Comm J Qual Patient Saf. 2021;47:120-126.
Efforts to reduce diagnostic error should include educational strategies for improving diagnosis. This article describes the development of a learning health system around diagnostic safety at one large, integrated health care system. The program identified missed opportunities in diagnosis based on clinician reports, patient complaints, and risk management, and used trained facilitators to provide feedback to clinicians about these missed opportunities as learning opportunities. Both facilitators and recipients found the program to be useful and believed it would improve future diagnostic safety.
Pulia M, Wolf I, Schulz L, et al. West J Emerg Med. 2020;21:1283-1286.
Antimicrobial stewardship is one strategy to improve antibiotic use to reduce hospital-acquired infections. In this editorial, the authors discuss negative effects of COVID-19 on antimicrobial resistance and antibiotic stewardship in the emergency department (ED) and approaches for optimizing ED stewardship during the pandemic.
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