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Bernstein SL, Kelechi TJ, Catchpole K, et al. Worldviews Evid Based Nurs. 2021;18:352-360.
Failure to rescue, the delayed or missed recognition of a potentially fatal complication that results in the patient’s death, is particularly tragic in obstetric care. Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, the authors describe the work system, process, and outcomes related to failure to rescue, and develop intervention theories.
Meyer AND, Giardina TD, Khawaja L, et al. Patient Educ Couns. 2021;104:2606-2615.
Diagnostic uncertainty can lead to misdiagnosis and delayed treatment. This article provides an overview of the literature on diagnosis-related uncertainty, where uncertainty occurs in the diagnostic process and outlines recommendations for managing diagnostic uncertainty.
Waddell AE, Gratzer D. Can J Psychiatry. 2021:070674372110365.
Safety gaps in mental health care offers a limited view if focused primarily on patient suicide. This commentary calls for Canadian psychiatric professionals to examine the safety of their patients from a system perspective to develop a research and practice improvement strategy.
Pinheiro LC, Reshetnyak E, Safford MM, et al. Med Care. 2021;59:901-906.
Prior research has found that racial/ethnic minorities may be at higher risk for adverse patient safety outcomes. This study evaluated racial disparities in self-reported adverse events based on cross-sectional survey data collected as part of a national, prospective cohort evaluating stroke mortality. Findings show that Black participants were significantly more likely to report a preventable adverse event attributable to poor care coordination (e.g., drug-drug interaction, emergency department visitor, or hospitalization) compared to White participants.
Marziliano A, Burns E, Chauhan L, et al. J Gerontol A Biol Sci Med Sci. 2022;77:e124-e132.
Many COVID-19 patients present with atypical symptoms, such as delirium, smell and taste dysfunction, or cardiovascular features. Based on inpatient electronic health record data between March 1 and April 20 of 2020, this cohort study examined the frequency of atypical presentation of COVID-19 among older adults. Analyses suggest that atypical presentation was often characterized by functional decline or altered mental status.

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.
Horberg MA, Nassery N, Rubenstein KB, et al. Diagnosis (Berl). 2021;8:479-488.
Missed or delayed diagnosis of sepsis can lead to serious patient harm. This study used a Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) “look-forward” analysis to measure potential misdiagnosis of sepsis in patients discharged from the emergency department (ED) with treat-and-release fluid and electrolyte disorders (FED) or altered mental status (AMS). FED and AMS were associated with a spike in sepsis hospitalizations in the 7-day period following the ED visit. The authors suggest SPADE could be used to compare sepsis diagnostic performance across institutions and regions; develop interventions for targeted subgroups; and update early warning systems for sepsis diagnosis.
Contreras J, Baus C, Brandt C, et al. J Am Pharm Assoc (2003). 2021;61:e94-e99.
Naloxone administration is used to mitigate the effects of opioid overdose. The FDA recommends health care professionals educate patients about naloxone when prescribing opioid medications. In this audit of community pharmacists, researchers found that naloxone counseling commonly often excluded concepts important to patient safety, such as assessment of opioid misuse or abuse, possible adverse effects, and naloxone storage.
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.
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.

Smith KM, Hunte HE, Graber ML. Rockville MD: Agency for Healthcare Research and Quality; August 2020. AHRQ Publication No. 20-0040-2-EF.

Telehealth is becoming a standard care mechanism due to COVID-19 concerns. This special issue brief discusses telediagnosis, shares system and associate factors affecting its reliability, challenges in adopting this mode of practice, and areas of research needed to fully understand its impact.   
Wiig S, Hibbert PD, Braithwaite J. Int J Qual Health Care. 2020;32.
The authors discuss how involving families in the investigations of fatal adverse events can improve the investigations by broadening perspectives and providing new information, but can also present challenges due to emotions, trust, and potential conflicts in perspectives between providers and families.
Lampert A, Haefeli WE, Seidling HM. J Patient Saf. 2020;16.
Through focus groups with patients, family caregivers and nurses, this study explored experiences with medication administration and perceived needs for assistance. Patients and caregivers were generally unaware of errors and primarily attributed administration problems to dosage form (eg, lack of confidence in using syringes). Participants identified lack of training or education about proper administration as contributing to administration errors.
Weingart SN, Nelson J, Koethe B, et al. Cancer Med. 2020.
Using a cohort of adults diagnosed with breast, colorectal, lung or prostate cancer, this study examined the relationship between oncology-specific triggers and mortality. It found that patients with at least one trigger had a higher risk of death than patients without a trigger; this association was strongest for nonmetastatic prostate cancer and nonmetastatic colorectal cancer. Triggers most commonly associated with increased odds of mortality were bacteremia, blood transfusion, hypoxemia and nephrology consultation. These findings support the validity of cancer-specific trigger tool but additional research is needed to replicate these findings.
Oliva EM, Bowe T, Manhapra A, et al. BMJ. 2020;386:m283.
Guidelines recommend safe opioid prescribing but also warn against sudden tapering or discontinuation of opioids, which can lead to harm among patients physically dependent on the medications. Using data from the Veterans Heath Administration (VA), this observational study examined the association between opioid treatment cessation and death from overdose or suicide. Researchers found an increased risk of death from overdose or suicide regardless of the length of treatment; the risk of death increased with longer treatment duration. The authors recommend that efforts to improve opioid safety include assessing risks that may place patients at risk for overdose or suicide whether they continue or stop opioid treatment.
Mamede S, de Carvalho-Filho MA, de Faria RMD, et al. BMJ Qual Saf. 2020;29:550-559.
There is uncertainty about the effectiveness of cognitive debiasing in reducing bias that can contribute to diagnostic error. Instead of focusing on the process of reasoning, this study examined whether an intervention directed at refining knowledge of a cluster of related disease can ‘immunize’ physicians against bias. Ninety-one internal medicine residents in Brazil were randomized to one of two sets of vignettes (reflecting diseases associated with either chronic diarrhea or jaundice) and compared/contrasted alternative diagnoses. After residents encountered one case of a disease, non-immunized residents twice as likely to give that incorrect diagnosis to a different (but similar) disease, resulting in a 40% decrease in diagnostic accuracy between immunized and non-immunized physicians.
Owen-Smith A, Stewart C, Sesay MM, et al. BMC Psych. 2020;20:40.
Prescription opioids are associated with an increased risk of adverse drug events and individual’s underlying mental health conditions may be more likely to be prescribed long-term opioid therapy. This study examined opioid treatment patterns among individuals with schizophrenia, bipolar disorder, or major depressive disorder (MDD) and found that having a diagnosis of bipolar disorder or MDD was associated with increased odds of receiving chronic opioid mediations, whereas a diagnosis of schizophrenia was not.
Hajibandeh S, Hajibandeh S, Satyadas T. The Surgeon. 2019;18:231-240.
Differences in weekend care for inpatients have been reported; however, the patient safety implications of the weekend effect are unclear. This meta-analysis pooled data from over 390,000 patients and found there was a higher risk of postoperative mortality among patients undergoing emergency general surgery on the weekends in the United States and Europe.