Lack of communication and interpersonal dynamics can contribute to failure to rescue. This study surveyed 262 surgical staff about perceived safety climate, but the authors did not find an association between organizational safety culture and failure to rescue or inpatient mortality.
Kandasamy S, Vanstone M, Colvin E, et al. J Eval Clin Pract. 2021;27:236-245.
Physicians often experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. Based on in-depth interviews with emergency, internal, and family medicine physicians, this qualitative study explores how physicians experience and learn from preventable medical errors. In addition to exploring themes around the physician’s emotional growth and professional development, the authors discuss the value of sharing and learning from these experiences for colleagues and trainees.
Zheng F ed. Surg Clin North Am. 2021;101(1):1-160.
Surgical safety is a recognized area of emphasis in patient safety improvement. Articles in this special issue cover topics such as human factors, checklists, teamwork, and telemedicine as a safe support mechanism.
Disruptive behavior is a recognized deterrent to safe communication, sharing of concerns and teamwork. This educational program highlights a study that measured the impact of unprofessional physician behavior on patient care and features Dr. William Cooper and Dr. Gerald Hickson as speakers.
Ricciardi R, Shofer M. J Nurs Care Qual. 2019;34:1-3.
This commentary discusses the importance of the nurse-patient relationship and engagement with patients and their family members to improve patient safety practices. The article also provides an overview of AHRQ resources intended to facilitate engagement between providers and their patients and family members.
A woman with acute myeloid leukemia presented to the emergency department (ED) with shortness of breath after receiving chemotherapy. As laboratory test results showed acute kidney injury and suggested tumor lysis syndrome, the patient was started on emergent hemodialysis. She experienced worsening dyspnea and was emergently intubated and transferred to the intensive care unit. There, her blood pressure began to drop, and she died despite aggressive measures.
Shapiro FE, ed. Int Anesthesiol Clin. 2019;57:1-162.
This publication presents patient safety concepts for anesthesia practice, including decision aids to educate and empower patients about anesthesia choice, environmental hazards, interpersonal communication, team training, and use of technology and simulation as educational tools.
Loftus TJ, Hall DJ, Malaty JZ, et al. Acad Psychiatry. 2019;43:581-584.
Resident physicians complete an annual evaluation of their training program, which includes questions on their program's culture of safety. Conducted among residency programs at a single academic medical center, this analysis found that residents in programs that emphasized safety culture had higher rates of passing their board certification exams on the first attempt.
Patient acuity and the need for interdisciplinary collaboration contribute to patient safety issues in trauma care. This qualitative study explored perceptions of handoff safety in pediatric trauma patients and found a high potential for information loss due to the rapidity of handoffs and the multiple disciplines involved.
Jones M, Scarduzio J, Mathews E, et al. Qual Health Res. 2019;29:1096-1108.
Simulation has been adopted as a valuable teaching tool in health care. In this study, researchers used relational dialectic theory and simulation to better understand the impact of interprofessional communication challenges on both team-based and individual disclosure of error.
Clinicians may experience distress after being involved in adverse events. This study of 4369 Dutch providers examined the prevalence and duration of clinicians' symptoms associated with involvement in an adverse event as well as the relationship between the degree of harm and symptom duration. As expected, clinicians reported symptoms such as hypervigilance, self-doubt, and discomfort following adverse events. These symptoms were more severe and long lasting for events with more serious harm to patients, compared to events with less severe harm. The authors call for organizations to provide support for clinicians involved in adverse events. A previous PSNet perspective discussed efforts to ameliorate the impact of errors on providers.
Wright B, Faulkner N, Bragge P, et al. Diagnosis (Berl). 2019;6:325-334.
The hectic pace of emergency care detracts from reliability. This review examined the literature on evidence, practice, and patient perspectives regarding diagnostic error in the emergency room. A WebM&M commentary discussed an incident involving a diagnostic delay in the emergency department.
Researchers deployed the Norwegian version of the Safety Attitudes Questionnaire, a measure of safety culture, across long-term care facilities and found significant variations in scores. They conclude that safety culture measurement may be useful to align resources with needs to support patient safety.
Ruskin KJ, Stiegler MP, Rosenbaum SH, eds. New York, NY: Oxford University Press; 2016. ISBN: 9780199366149.
The perioperative setting is a high-risk environment. This publication discusses the clinical foundations and application of safety concepts in perioperative practice. Chapters cover topics such as human factors, error management, cognitive aids, safety culture, and teamwork.
Casali G, Cullen W, Lock G. J Thorac Dis. 2019;11:S998-S1008.
Nontechnical skills, such as teamwork, communication, and leadership, are essential human-centered components of safe surgical practice. This commentary discusses contextual characteristics needed to support nontechnical skill development to improve health care outcomes. The authors recommend a cultural shift away from focusing on technical performance to one that incorporates training in nontechnical skills.
Sturrock J. Edinburgh, Scotland: The Scottish Government; May 2019. ISBN: 9781787817760.
Disrespectful and unprofessional behaviors are a common problem in health care. The report examines cultural issues at a National Health Service trust that affected the transparency needed to report disruptive behaviors and that limited conversation needed to facilitate local actions and improvement. Recommendations for the leadership, organizational, and system levels are provided to enable constructive change.
Davidson M, Brennan PA. Br J Oral Maxillofac Surg. 2019;57:407-411.
Aviation has provided health care with insights regarding how systems approaches, blame-free reporting, and teamwork can prevent failure. This commentary summarizes tactics used in aviation that have been applied to surgery in support of efforts to reduce patient harm.
Higham H, Greig PR, Rutherford J, et al. BMJ Qual Saf. 2019;28:672-686.
Nontechnical skills, such as teamwork and communication, are critical to safe care delivery, but can be difficult to measure. This systematic review examined validated approaches for assessing nontechnical skills using direct observation. Researchers analyzed 118 articles that discussed 76 unique tools for measuring nontechnical skills. This wide range of instruments assessed individuals or teams in various health care settings, either in simulation or actual clinical practice. They identified substantial variability in how these approaches were validated and whether individual studies reported the usability of each tool. The authors spotlight the need for standardization in how to develop, test, and implement assessments of nontechnical skills. A related editorial discusses the findings of this systematic review in the context of previous research and advocates for future work to standardize assessment of nontechnical skills in health care.
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