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James L, Elkins-Brown N, Wilson M, et al. Int J Nurs Stud. 2021;123:104041.
Many hospitals have adopted a 12-hour work shift for nurses and some studies have shown a resulting increase in burnout and decrease in patient safety. In this study, researchers assessed simulated nursing performance, cognition, and sleepiness in day nurses and night nurses who worked three consecutive 12-hour shifts. Overall results indicated nurses on both shifts mostly maintain their abilities on the simulated nursing performance assessment despite reporting increased sleepiness and fatigue. However there was more individual variation in cognition and some domains of performance.
Fatemi Y, Coffin SE. Diagnosis (Berl). 2021;8:525-531.
Using case studies, this commentary describes how availability bias, diagnostic momentum, and premature closure resulted in delayed diagnosis for three pediatric patients first diagnosed with COVID-19. The authors highlight cognitive and systems factors that influenced this diagnostic error.

Arvidsson L, Lindberg M, Skytt B, et al. J Clin Nurs. Epub 2021 Jul 6. 

 

Healthcare associated infections (HAI) affect thousands of hospitalized patients each year. This study evaluated working conditions that impact risk behaviors, such as missed hand hygiene, that may contribute to HAI. Main findings indicate that interruptions and working with colleagues were associated with increased risk behaviors.

A 34-year-old morbidly obese man was placed under general anesthesia to treat a pilonidal abscess. Upon initial evaluation by an anesthesiologist, he was found to have a short thick neck, suggesting that endotracheal intubation might be difficult. A fellow anesthetist suggested use of video-laryngoscopy equipment, but the attending anesthesiologist rejected the suggestion. A first-year resident attempted to intubate the patient but failed.

Debesay J, Kartzow AH, Fougner M. Nurs Inq. 2021;29:e12421.
Previous studies have shown that ethnic minority patients are at an increased risk of adverse events. Using critical incidents and provider reflections, this study highlights the challenges faced by healthcare providers when providing care for ethnic minority patients. Similar reflection processes in the work environment may contribute to better coping strategies and improved relationships with ethnic minority patients. 
Brown SD. Pediatr Radiol. 2021;51:1070-1075.
Misdiagnosis of child abuse has far-reaching implications. This commentary discusses the ethical tensions faced by pediatric radiologists of both over- and under-diagnosing child abuse. The author suggests ways that physicians and professional societies can partner with legal advocates to create a more balanced pool of experts to alleviate perceptions of bias and acknowledge harms of misdiagnosed child abuse.

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.

Weiser S. The New Yorker and Retro Report; 2021.

Disparities in maternal care have become apparent as a public health concern during the COVID-19 pandemic. This short film spotlights inequities and biases that Black mothers face, that reduce the safety of their care. Midwives are offered as a strategy for improving the safety of maternal care in this patient population.

A 65-year-old man with a history of type 2 diabetes mellitus, hypertension, and coronary artery disease was transferred from a Level III trauma center to a Level I trauma center with lower extremity paralysis after a ground level fall complicated by a 9-cm abdominal aortic aneurysm and cervical spinal cord injury. Post transfer, the patient was noted to have rapidly progressive ascending paralysis. Magnetic resonance imaging (MRI) revealed severe spinal stenosis involving C3-4 and post-traumatic cord edema/contusion involving C6-7.

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.
Velmahos CS, Kokoroskos N, Tarabanis C, et al. World J Surg. 2021;45:690-696.
The authors retrospectively reviewed records for 150 patients undergoing emergency surgery who experienced a preventable complication and/or death. The most common preventable complication was surgical site infections. The majority of complications were attributed to personal performance (technical or judgement issues) and a small proportion (3%) were attributed to systemic issues, such as poor communication or inadequate protocols.

A 24-year-old woman with type 1 diabetes presented to the emergency department with worsening abdominal pain, nausea, and vomiting. Her last dose of insulin was one day prior to presentation. She stopped taking insulin because she was not tolerating any oral intake. The admitting team managed her diabetes with subcutaneous insulin but thought the patient did not meet criteria for diabetic ketoacidosis (DKA), but after three inpatient days with persistent hyperglycemia, blurred vision, and altered mental status, a consulting endocrinologist diagnosed DKA.

Shannon EM, Zheng J, Orav EJ, et al. JAMA Network Open. 2021:4(3);e213474.

This cross-sectional study examined whether racial/ethnic disparities in interhospital transfers (IHT) for common medical diagnoses such as heart failure, acute myocardial infarction, stroke, and sepsis, impact mortality outcomes. The authors analyzed 899,557 patients and reported that Black patients had lower odds of IHT compared to White patients, while Hispanic patient had higher odds of IHT compared with White patients. The authors propose several possible explanations including differences in Black and Hispanic willingness to transfer, impact of insurance status and reimbursement rates, coding inaccuracies, and other complex dynamics for their findings.
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.
Kolodzey L, Trbovich PL, Kashfi A, et al. Ann Surg. 2020;272:1164-1170.
Health systems weaknesses can hinder safe patient care. Based on recordings of complex laparoscopic general surgery procedures, this qualitative study identified both safety threats and resilience supports across multiple systems engineering categories. Safety threats associated with the physical environment (e.g., workspace design/setup), tasks, organization (e.g., unsafe staffing), and equipment (e.g., unclear instructions) were most common. Resilience supports were primarily attributed to clinician behaviors.  
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.