Avesar M, Erez A, Essakow J, et al. Diagnosis (Berl). 2021;8:358-367.
Disruptive and rude behavior can hinder teamwork and diminish patient safety. This randomized, simulation-based study including attendings, fellows, and residents explored whether rudeness during handoff affects the likelihood for challenging a diagnostic error. The authors found that rudeness may disproportionally hinder diagnostic performance among less experienced physicians.
Demaria J, Valent F, Danielis M, et al. J Nurs Care Qual. 2021;36:202-209.
Little empirical evidence exists assessing the association of different nursing handoff styles with patient outcomes. This retrospective study examined the incidence of falls during nursing handovers performed in designated rooms away from patients (to ensure confidentiality and prevent interruptions and distractions). No differences in the incidence of falls or fall severity during handovers performed away from patients versus non-handover times were identified.
Pelaccia T, Messman AM, Kline JA. Patient Edu Couns. 2020;103:1650-1656.
The hectic and complex environment of emergency care can reduce diagnostic safety. This article discusses clinical reasoning and decision-making strategies used by emergency medicine physicians, contributing factors to diagnostic errors occurring in emergency medicine (e.g., overconfidence, cognitive stress, anchoring bias), and strategies to reduce the risk of error. A previous WebM&M commentary discussed an incident involving diagnostic delay in the emergency department.
O’Donovan R, McAuliffe E. BMC Health Serv Res. 2020;20:810.
Organizational cultures that encourage psychological safety have been shown to increase safe healthcare. The authors used survey, observational, and interview data to explore psychological safety within four healthcare teams in one hospital. While survey results indicated a high level of psychological safety, observations and interviews identified examples of situations resulting in lower levels of psychological safety, such as absence of learning behavior, low levels of support from other team members, and lack of familiarity among team members.
Durning S, Holmboe E, Graber ML, eds. Diagnosis(Berl). 2020;7(3):151-344.
Challenges to effective clinical reasoning reduce diagnostic accuracy. This special issue provides background for a new approach to clinical reasoning: situativity. The articles explore the four complementary facets of the concept -- situated cognition; distributed cognition; embodied cognition; and ecological psychology – and describes how situativity can enhance diagnosis through a holistic approach to education, assessment, and research.
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.
Plint AC, Stang A, Newton AS, et al. BMJ Qual Saf. 2021;30:216-227.
This article describes emergency department (ED)-related adverse events in pediatric patients presenting to the ED at a pediatric hospital in Canada over a one-year period. Among 1,319 patients at 3-months follow-up, 33 patients (2.5%) reported an adverse event related to their ED care. The majority of these events (88%) were preventable. Most of the events involved diagnostic (45.5%) or management issues (51.5%) and resulted in symptoms lasting more than one day (72.7%).
Sanson G, Marino C, Valenti A, et al. Heart & Lung. 2020;49:407-414.
Prospective observational study examined whether nursing complexity level predicts adverse event risk among patients transferred from the ICU to the discharge ward. In this 13-bed ICU, researchers found that various factors including level of acuity and nursing complexity predated risk of adverse events (AEs); patients who exceeded a predetermined complexity threshold were at 3-times greater risk of AEs.
Härkänen M, Vehviläinen‐Julkunen K, Murrells T, et al. Journal of Nursing Scholarship. 2019;52.
This retrospective study used descriptive statistics, manual analysis, and text mining of medication-related incident reports and staffing (N = 72,390) in England and Wales. The text mining was conducted with SAS Text Minor tool. Effective trigger terms included “short staffing”, “workload”, and “extremely busy”. The authors concluded that inadequate staffing, workload, and working in haste may increase the risk for errors. The key importance of this article is the use of an automated system to analyze incident reports.
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