Bernstein SL, Kelechi TJ, Catchpole K, et al. Worldviews Evid Based Nurs. 2021;18:352-360.
Failure to rescue, the delayed or missed recognition of a potentially fatal complication that results in the patient’s death, is particularly tragic in obstetric care. Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, the authors describe the work system, process, and outcomes related to failure to rescue, and develop intervention theories.
Petrosoniak A, Fan M, Hicks CM, et al. BMJ Qual Saf. 2021;30:739-746.
Trauma resuscitation is a complex, specialized process with a high risk for errors. Researchers analyzed videotapes of in situ simulations to evaluate latent safety events occurring during trauma resuscitation. Themes influencing latent safety events related to physical workspace, mental model formation, equipment, unclear accountability, demands exceeding individuals’ capacity, and task-specific issues.
Patel J, Otto E, Taylor JS, et al. Dermatol Online J. 2021;27(3).
In an update to their 2010 article, this review’s authors summarized the patient safety literature in dermatology from 2009 to 2020. In addition to topics covered in the 2010 article, this article also includes diagnostic errors related to telemedicine, laser safety, scope of practice, and infections such as COVID-19. The authors recommend further studies, and reports are needed to reduce errors and improve patient safety.
Stokke R, Melby L, Isaksen J, et al. BMC Health Serv Res. 2021;21:553.
This article explored the interface of technology and patients in home care. Researchers identified three work processes that contribute to patient safety: aligning people with technologies, being alert and staying calm, and coordinating activities based on people and technology. Topics for future research should include the division of labor on home care shifts, the need for new routines and education in telecare for care workers, and how decisions are made regarding home technology.
Farhat A, Al‐Hajje A, Csajka C, et al. J Clin Pharm Ther. 2021;46:877-886.
Several tools have been developed to reduce potentially inappropriate prescribing. This study explored the economic and clinical impacts of two tools, STOPP/START and FORTA (Fit fOR The Aged list). Randomized controlled trials (RCTs) using those tools demonstrated significant clinical and economic impact in geriatric and internal medicine. Due to the low number of RCT studies evaluating these tools, additional studies are warranted.
Fuller G, Pandor A, Essat M, et al. J Trauma Acute Care Surg. 2021;90:403-412.
Prehospital triage tools are used to differentiate between patients who need emergency care at a major trauma center (MTC) and those that may receive adequate care at a non-MTC. Accurate triage tools are necessary to ensure that patients are not over- or undertriaged. This review found high variability in sensitivity and specificity across geriatric triage tools indicating some patients may not be receiving the specialized trauma care they need. The authors highlight several future research targets including development of relevant reference standards and balancing the risk between over- and undertriage.
Fridrich A, Imhof A, Schwappach DLB. J Patient Saf. 2021;17:217-222.
Checklists are used across clinical areas. Following the publication of the World Health Organization’s (WHO) Surgical Safety Checklist in 2009, other organizations developed their own checklists or adapted the WHO Surgical Safety Checklist for local settings. The authors analyzed 24 checklists used in 18 Swiss hospitals, identified major differences between study checklists and reference checklists and provided recommendations for future research regarding the effectiveness of surgical safety checklists.
Hodkinson A, Tyler N, Ashcroft DM, et al. BMC Med. 2020;18:313.
Medication errors represent a significant source of preventable harm. This large meta-analysis, including 81 studies, found that approximately 1 in 30 patients is exposed to preventable medication harm, and more than one-quarter of this harm is considered severe or life-threatening. Preventable medication harm occurred most frequently during medication prescribing and monitoring. The highest rates of preventable medication harm were seen in elderly patient care settings, intensive care, highly specialized or surgical care, and emergency medicine.
The COVID-19 pandemic has dramatically affected the psychological and emotional well-being of health care workers. This article summarizes the COVID-19-related psychological effects on healthcare workers and the detrimental impact on team effectiveness. The authors recommended actions to mitigate the effects of stress on team performance and patient outcomes and discuss how teams can recover and learn from the current crisis to prepare for future challenges.
Ashcroft J, Wilkinson A, Khan M. J Surg Educ. 2020;78:245-264.
This systematic review explored the different approaches taken by the United States and the United Kingdom to implement crew resource management (CRM) training. CRM in the United Kingdom had an emphasis on physicians and focused on skills outcomes using pre- and post-training questionnaires, whereas CRM in the United States focused on behavior outcomes and nontechnical skills utilizing multidisciplinary teams.
Rainbow JG, Drake DA, Steege LM. West J Nurs Res. 2020;42:332-339.
This study explored the relationships between nurse fatigue, burnout, psychological well-being, team vitality, and patient safety, and the role of presenteeism as a potential mediator. Authors found strong relationships between workplace influences and job-stress presenteeism, and between job-stress presenteeism and patient safety outcomes, including lower rates of event reporting and perceptions of patient safety.
Härkänen M, Turunen H, Vehviläinen-Julkunen K. J Patient Saf. 2020;16.
This study compared medication errors detected using incident reports, the Global Trigger Tool method, and direct observations of patient records. Incident reports and the Global Trigger Tool more commonly identified medication errors likely to cause harm. Omission errors were commonly identified by all three methods, but identification of other errors varied. For example, incident reports most commonly identified wrong dose and wrong time errors. The contributing factors also varied by method, but in general, communication issues and human factors were the most common contributors.
Storesund A, Haugen AS, Flaatten H, et al. JAMA Surg. 2020;155:562-570.
This study assessed the impact of combined use of two surgical safety checklists on morbidity, mortality, and length of stay – the Surgical Patient Safety System (SURPASS) is used to address preoperative and postoperative care, and the World Health Organization surgical safety checklist (WHO SSC) is used for perioperative care. In addition to existing use of the WHO SSC, the SURPASS checklist was implemented in three surgical departments in one tertiary hospital in Norway. Results demonstrated that combined use of these checklists was associated with reduced complications reoperations, and readmissions, but combined use did not impact mortality or length of stay.
The Joint Commission recognizes potential overuse of diagnostic imaging, particularly computed tomographic (CT) scans, to be a patient safety risk due to excess radiation exposure. This study sought to determine whether low-dose whole-body CT (WBCT), which exposes the patient to less radiation, has similar accuracy to standard-dose WBCT. A cohort of over 1,000 patients with suspected blunt trauma were prospectively recruited; half received standard-dose WBCT and the other half received low-dose WBCT. The authors found that use of low-dose WBCT did not increase risk of missed injury diagnosis, while reducing median radiation exposure by almost half.
Appelbaum N, Clarke J, Feather C, et al. BMJ Open. 2019;9:e032686.
While medication errors during paediatric resuscitation are considered common, little information about the processes that contribute to them has been gathered. This prospective observational study in a large English teaching hospital describes the incidence, nature and severity of medication errors made by 15 teams, each comprised of two doctors and two nurses, during simulated paediatric resuscitations. Clinically significant errors were made in 11 of the 15 cases, most due to discrepancies in drug ordering, preparation and administration. The authors recommend additional research into new approaches to protecting patients in paediatric emergency settings.
Westman M, Takala R, Rahi M, et al. World Neurosurg. 2019.
Checklists have been shown to improve patient safety in various surgical specialties but this systematic review found that evidence of their impact in neurosurgery is still limited given emerging technologies such as robotics and artificial intelligence. Studies with larger neurosurgical patient populations, as well as in relation to robotic neurosurgery, are needed to understand the impact of checklists in neurosurgery.
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