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ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares reported vaccine errors and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.
Biquet J-M, Schopper D, Sprumont D, et al. J Patient Saf. 2021;17:e1738-e1743.
Few medical humanitarian organizations have patient safety reporting and analysis systems. Interviews with medical and paramedical staff working in international humanitarian organizations expressed high expectations for organizational leadership to establish clear patient safety and medical error management policies.  
Pryce A, Unwin M, Kinsman L, et al. Int Emerg Nurs. 2020;54:100956.
Emergency department (ED) overcrowding and prolonged ED stays can lead to adverse patient outcomes. This study examined patient flow bottlenecks in the ED and several factors posing risks to patient safety, such as prolonged time to triage and use of makeshift spaces (which may have inadequate staffing allocations or lack necessary equipment).
A 55-year old woman became unarousable with low oxygen saturation as a result of multiple intravenous benzodiazepine doses given overnight. The benzodiazepine was ordered following a seizure in the intensive care unit (ICU) and was not revised or discontinued upon transfer to the floor; several doses were given for different indications - anxiety and insomnia.
Cinar P, Kubal T, Freifeld A, et al. J Natl Compr Canc Netw. 2020;18:504-509.
This article reviews strategies to mitigate transmission of COVID-19 among patients with cancer and for the healthcare workers providing care to those patients. The authors recommend several approaches ensure patient safety, including COVID-19 prescreening/screening via telemedicine, greater utilization of tele-oncology, limiting surgeries and procedures to only essential, urgent, or emergent cases, and switching therapies to oral (versus infusion) when possible. They also propose measures focused on healthcare worker safety, including appropriate use of personal protective equipment (PPE), use of daily screening tools and/or temperature checks, greater use of telework and limited onsite staff, and clear stay-at-home and return-to-work guidelines.
Needleman J, Liu J, Shang J, et al. BMJ Qual Saf. 2020;29:10-18.
Prior research has shown that nurse staffing is an important consideration with regard to patient safety. Lower nurse-to-patient ratios are associated with increased mortality and have prompted policies mandating particular nurse staffing ratios, especially in the intensive care unit. To address the criticism that previous studies have compared different institutions with higher nurse staffing to those with lower staffing levels and that there may be other reasons for observed differences in patient outcomes, this study evaluated the relationship between inpatient mortality and exposure to shifts with decreased registered nurse staffing, lower nursing support staffing, and increased patient turnover at three sites within a single academic medical center. Consistent with prior studies, researchers found an association between low nurse and nursing support staffing and increased patient mortality; there was no association between patient turnover and mortality. An accompanying editorial advocates for additional prospective research on interventions put in place to address nurse staffing.
Neprash HT, Barnett ML. JAMA Netw Open. 2019;2:e1910373.
The root causes of the opioid epidemic are complex, but inappropriate prescribing of opioids (which includes both prescribing opioids in situations where they are not indicated as well as excessive prescribing for appropriate indications) is a major contributor. Prior studies of outpatient antibiotic prescribing have shown that rates of inappropriate prescribing rise toward the end of clinicians' clinic sessions. This cross-sectional study used data from 5603 primary care physicians for acute painful conditions to analyze whether a similar relationship exists for opioid prescribing. Investigators found that the likelihood of opioid prescribing rose considerably as the workday progressed; clinicians were also more likely to prescribe opioids if their appointments were running late. In contrast, prescriptions for nonopioid therapies did not change in relation to appointment time. Although the magnitude of these effects was smaller than the variation in opioid prescribing rates between physicians found in other studies, these findings confirm that production pressure and decision fatigue contribute to inappropriate prescribing and should be addressed in quality improvement efforts to reduce opioid use.
Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.
Surgical specimen and laboratory process problems can affect diagnosis. This publication examines factors that contribute to errors across the surgical pathology process and reviews strategies to reduce their impact on care. Chapters discuss areas of focus to encourage process improvement and error response, such as information technology, specimen tracking, root cause analysis, and disclosure.
Barger LK, Sullivan JP, Blackwell T, et al. Sleep. 2019;42.
In this clustered-randomized trial across six academic medical centers, researchers examined the impact of resident shift duration on hours slept and worked per week during pediatric intensive care unit rotations. They found that residents assigned to extended duration shifts lasting 24 hours or longer worked more hours per week and slept fewer hours per week compared to residents assigned to work shifts lasting 16 hours or shorter.
Basner M; Asch DA; Shea JA; Bellini LM; Carlin M; Ecker AJ; Malone SK; Desai SV; Sternberg AL; Tonascia J; Shade DM; Katz JT; Bates DW; Even‑Shoshan O; Silber JH; Small DS; Volpp KG; Mott CG; Coats S; Mollicone DJ; Dinges DF; iCOMPARE Research Group.
This cluster-randomized trial compared an internal medicine residency schedule that adhered to 2011 duty hour regulations to a flexible schedule that maintained an overall 80-hour work week. Self-reported sleepiness and measured sleep duration did not differ by group, but residents in the flexible programs performed worse on psychomotor vigilance testing, a measure of alertness. The authors recommend implementing fatigue-management training during residency.
Mays JA, Mathias PC. J Am Med Inform Assoc. 2019;26:269-272.
Point-of-care test results are often manually transcribed into the electronic health record, which introduces risks of manual transcription errors. The authors of this study took advantage of a redundant workflow in which point-of-care blood glucose results were uploaded and also manually entered by staff. They estimate that 5 in 1000 manually entered results contain clinically significant transcription errors and call for interfacing point-to-care instruments as a patient safety strategy.
Sun E, Mello MM, Rishel CA, et al. JAMA. 2019;321:762-772.
Scheduling overlapping surgeries has raised substantial patient safety concerns. However, research regarding the impact of concurrent surgery on patient outcomes has produced conflicting results. In this multicenter retrospective cohort study, researchers examined the relationship between overlapping surgery and mortality, postoperative complications, and surgery duration for 66,430 surgeries between January 2010 and May 2018. Although overlapping surgery was not significantly associated with an increase in mortality or complications overall, researchers did find a significant association between overlapping surgery and increased length of surgery. An accompanying editorial discusses the role of overlapping surgery in promoting the autonomy of those in surgical training and suggests that further research is needed to settle the debate regarding the impact of overlapping surgery on patient safety.
Gupta A, Jain S, Croft C. JAMA. 2019;321:504-505.
The authors present a case in which an unnecessary procedure was incorrectly performed on a patient who had opted to pursue hospice care. They highlight factors contributing to the error including those related to use of the electronic health record.
Dahm MR, Georgiou A, Herkes R, et al. Diagnosis (Berl). 2018;5:215-222.
Inadequate test result follow-up places patients at risk of delayed diagnosis, especially in the ambulatory setting. Diverse stakeholders in Australia established an agenda for enhancing test result management, which included better governance, improved use of technology, and consistent patient engagement. A WebM&M commentary explored two incidents where poor test result follow-up led to patient harm.
Sanaiha Y, Ou R, Ramos G, et al. Ann Thorac Surg. 2018;106:1767-1773.
Studies have demonstrated worse clinical outcomes for patients admitted to the hospital on weekends compared to weekdays—referred to as the weekend effect. This retrospective study found that patients undergoing elective cardiac surgery who were discharged on the weekend or a holiday did not experience higher odds of all-cause 30-day readmission than patients discharged on a weekday.
Potts JR. Am J Surg. 2017;214:974-978.
Insufficient supervision can limit resident education, which may increase risks to patient safety. This commentary outlines factors that reduce the effectiveness of general surgery resident supervision and provides suggestions to augment supervision, including developing policies that outline when resident supervision is required and educating hospital executives about the need for appropriate oversight of care delivered by trainees.

Imrie KR, Frank JR, Parshuram CS, eds. BMC Med Educ. 2014;14(suppl1):S1-S18.

Articles in this special issue discuss the impact of resident duty hours (such as how they can affect education, resident well-being, and patient outcomes), explore challenges associated with addressing resident fatigue, and describe strategies for hospitals to adapt to changing work hour requirements.
Smith-Miller CA, Shaw-Kokot J, Curro B, et al. J Nurs Adm. 2014;44:487-94.
Clinician fatigue can contribute to poor decision-making and clinical performance. This review explores the prevalence of nurse fatigue and describes work-related factors that influence fatigue among nurses. The authors suggest implementing institution-wide policies and educating nurses and administrators about risks related to fatigue to address the problem.
Sabin J, Subbe CP, Vaughan L, et al. Clin Med (Lond). 2014;14:462-7.
Many studies have explored how staffing levels influence safe and reliable patient care. Focusing on physician staffing in acute internal medicine, this review describes the way workload, process timing, patient complexity, service set-up, and team skill mix affect staffing needs.