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Ellis R, Hardie JA, Summerton DJ, et al. Surg. 2021;59:752-756.
Many non-urgent, non-cancer surgeries were postponed or canceled during COVID-19 surges resulting in a potential loss of surgeons’ “currency”. This commentary discusses the benefits of, and barriers to, dual surgeon operating as a way to increase currency as elective surgeries are resumed.

A seven-year-old girl with esophageal stenosis underwent upper endoscopy with esophageal dilation under general anesthesia. During the procedure, she was fully monitored with a continuous arterial oxygen saturation probe, heart rate monitors, two-lead electrocardiography, continuous capnography, and non-invasive arterial blood pressure measurements.

This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

Dickinson KL, Roberts JD, Banacos N, et al. Health Secur. 2021;19:s14-s26.
The COVID-19 pandemic highlighted the continued existence of structural racism and its disproportionate impact on the health of communities of color. This study examines the experiences of non-White and White communities and the negative impact of structural racism on the non-White communities. The authors call for bold action emphasizing the need for structural changes.  

Gandhi TK. NEJM Catalyst. Epub 2021 May 27.

The COVID-19 pandemic has shown a spotlight on bias, disparities, and inequity in the healthcare system. The author advocates using the same strategies to reduce inequities that were used to improve patient safety: 1) culture, leadership, and governance; 2) learning systems; 3) workforce; and 4) patient engagement.
Brockett-Walker C, Lall M, Evans DD, et al. Adv Emerg Nurs J. 2021;43:89-101.
This review critiques a 2016 article (link below) which found unconscious, implicit bias can negatively impact patient care when emergency department providers are under increased cognitive stress. The authors propose strategies for educators and institutions to combat implicit bias including self-awareness, stress reduction, and respectful communication.
Ekkens CL, Gordon PA. Holist Nurs Pract. 2021;35:115-122.
Despite system-level interventions, medication administration errors (MAE) continue to occur. Nurses at an American hospital were trained in mindful thinking in an effort to reduce MAE. After three months, nurses who received the mindfulness training had fewer medication errors, and less severe errors, than nurses who did not receive the training. Mindful thinking was effective at reducing medication administration errors and the authors recommend trainings be part of nurses’ orientation and continuing education.

Two separate patients undergoing urogynecologic procedures were discharged from the hospital with vaginal packing unintentionally left in the vagina. Both cases are representative of the challenges of identifying and preventing retained orifice packing, the critical role of clear handoff communication, and the need for organizational cultures which encourage health care providers to communicate and collaborate with each other to optimize patient safety.

Gopal DP, Chetty U, O'Donnell P, et al. Future Healthc J. 2021;8:40-48.
Provider implicit bias can impact patient safety through clinical misdiagnosis, pain management, and poor patient outcomes. This literature review sought to define implicit bias and identify the impact on clinical practice and research. The authors found that no effective debiasing strategies seem to currently exist. A December 2020 WebM&M commentary discusses how implicit bias can contribute to poor communication between healthcare teams.
Minehart RD, Bryant AS, Jackson J, et al. Obstet Gynecol Clin North Am. 2021;48:31-51.
Improving maternal safety and reducing disparities in maternal morbidity and mortality are national priorities. This article discusses inequities in maternal health outcomes and provision of care, factors involved in the relationship between race and health (e.g., racism, social status, health behaviors), and efforts at the national-, state-, and hospital-level to improve obstetric care and outcomes for Black mothers.

AHA Team Training.
 

The COVID-19 crisis requires cooperation and coordination of organizations and providers to address the persistent challenges presented by the pandemic. This on-demand video collection reinforces core TeamSTEPPS; methods that enhance clinician teamwork and communication skills to manage care safety during times of crisis. 
Lewandowska K, Weisbrot M, Cieloszyk A, et al. Int J Environ Res Public Health. 2020;17:8409.
Alarm fatigue, which can lead to desensitization and threaten patient safety, is particularly concerning in intensive care settings. This systematic review concluded that alarm fatigue may have serious consequences for both patients and nursing staff. Included studies reported that nurses considered alarms to be burdensome, too frequent, interfering with patient care, and resulted in distrust in the alarm system. These findings point to the need for a strategy for alarm management and measuring alarm fatigue.  
Berg TA, Hebert SH, Chyka D, et al. Simul Healthc. 2021;16:e136-e141.
Nurses are often responsible for medication administration at the bedside. This simulation study found that a smart phone app providing just-in-time medication administration information could reduce the occurrence of medication administration errors by nursing students. 
Capers Q, Bond DA, Nori US. Chest. 2020;158:2688-2694.
Implicit and explicit bias can reduce the effectiveness and safety of care. Using four case studies, this article highlights how healthcare professionals can be influenced by biases, how these biases threaten patient safety, and strategies to mitigate biases and attenuate the impact of bias and racism on patient outcomes.

After a breast mass was identified by a physician assistant during a routine visit, a 60-year-old woman received a diagnostic mammogram and ultrasound. The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably benign” findings. When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred for a biopsy.

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.   
Traylor AM. Am Psychol. 2021;76:1-13.
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.
Lerner JE, Martin JI, Gorsky GS. Sex Res Social Pol. 2020;18:409-426.
This study used national survey data to examine avoidance of healthcare services among transgender, gender nonconforming, and non-binary people. Researchers found that nearly one quarter of respondents reported not seeking healthcare when necessary because they anticipated being disrespected or mistreated by healthcare professionals. Previous experience with certain discriminatory behavior such as invasive questions, refusal of care, verbal harassment, as well as cost and needing to educate providers, were strong predictors of healthcare avoidance.
Raffel KE, Kantor MA, Barish P, et al. BMJ Qual Saf. 2020;29:971-979.
This retrospective cohort study characterized diagnostic errors among adult patients readmitted to the hospital within 7 days of hospital discharge. Over a 12-month period, 5.6% of readmissions were found to contain at least one diagnostic error during the index admissions. These diagnostic errors were primarily related to clinician diagnostic reasoning, including failure to order needed tests, erroneous interpretation of tests, and failure to consider the correct diagnosis. The majority of the diagnostic errors resulted in some form of clinical impact, including short-term morbidity and readmissions.