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.
Han D, Khadka A, McConnell M, et al. JAMA Netw Open. 2020;3:e2024589.
Unexpected death or serious disability of a newborn is considered a never event. A cross-sectional analysis including over 5 million births between 2011 and 2017 in the United States found unexpected newborn death was associated with a significant increase in use of procedures to avert or mitigate fetal distress and newborn complications (e.g., cesarean delivery, antibiotic use for suspected sepsis). These findings could reflect increased caution among clinicals or indicate more proactive attempts to identify and address potential complications.
Naloxone administration in inpatient and outpatient settings is used to mitigate the effects of opioid overdose. This study, conducted at one academic medical center, found that an increasing number prehospital naloxone doses for suspected opioid overdose was significantly associated with an increased likelihood of adverse events (AEs) in the emergency department (ED).
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.
Berry D, Wakefield E, Street M, et al. J Adv Nurs. 2020;76:2235-2252.
Isolation for infection prevention and control is beneficial but may result in unintended consequences for patients (e.g., less attention, suboptimal documentation and communication, higher risk of preventable adverse events). This systematic review did not identify any evidence suggesting that adult patients in isolation precautions for infection control are more likely to experience clinical deterioration or hospital-acquired complications compared to non-insolated patients.
This article discusses the tension between evidence generation from observational studies and rigorous randomized controlled trials to treat COVID-19 and important safety considerations, such as use of unproven therapies.
Duhn L, Godfrey C, Medves J. Health Expect. 2020;23:979-991.
This scoping review characterized the evidence base on patients’ attitudes and behaviors concerning their engagement in ensuring the safety of their care. The review found increasing interest in patient and family engagement in safety and identified several research gaps, such as a need to better understand patients’ attitudes across the continuum of care, the role of family members, and engagement in primary care safety practices.
Dahlke SA, Hunter KF, Negrin K. Int J Older People Nurs. 2019;14:e12220.
Care for older hospitalized patients can be complex due to multimorbidities and polypharmacy. This review found that restraint use and limiting mobility to prevent falls can result in functional losses in geriatric patients. The authors suggest multidisciplinary approaches to shifting the goals of nursing care to focus on preserving and restoring function in older patients.
This systematic review of falls among individuals with speech, language, and voice disability found that these populations are often excluded from studies of falls. However, there is some evidence that communication disability leads to increased risk of falls and the authors call for further study for this population.
Sharma AE, Rivadeneira NA, Barr-Walker J, et al. Health Aff (Millwood). 2018;37:1813-1820.
Patient and family engagement efforts can affect health care quality and safety. This review examined the research on patient engagement efforts and found evidence of robust examinations of patient engagement related to patient self-management of anticoagulation medications. However, there was mixed-quality evidence on patient involvement in medication administration errors, documentation and scheduling accuracy, hospital readmissions, and health care–associated infections. They recommend areas of research needed to guide the application of patient engagement strategies.
Cooper J, Williams H, Hibbert P, et al. Bull World Health Organ. 2018;96:498-505.
The World Health Organization International Classification for Patient Safety enables measurement of safety incident severity. In this study, researchers describe how they adapted the system to primary care. Their harm severity classification emphasizes psychological harm, hospitalizations, near misses, and uncertain outcomes in addition to traditional markers of harm.
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