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.
Rosenthal CM, Parker DM, Thompson LA. JAMA Pediatr. 2022;176:119-120.
The care of child abuse victims is affected by resource, racial and infrastructure challenges. This commentary describes how the systemic weaknesses catalyzed by poor data collection approaches contribute to misdiagnosis and suggests that successes be mined to minimize the proliferation of continued disparities in this patient population.
Burrus S, Hall M, Tooley E, et al. Pediatrics. 2021;148:e2020030346.
Based on analysis of four years of data submitted to the Child Health Patient Safety Organization (CHILDPSO), researchers sought to identify types of serious safety events and contributing factors. Three main groups of serious safety events were identified: patient care management, procedural errors, and product or device errors. Contributing factors included lack of situational awareness, process failures, and failure to communicate effectively.
Casey T, Turner N, Hu X, et al. J Safety Res. 2021;78:303-313.
Many factors influence the success of implementation and sustainment of patient safety interventions. Through a review of 38 research articles about safety training, researchers were able to develop a theoretical framework integrating safety training engagement and application of learned skills. They discuss individual, organizational, and contextual factors that influence safety training engagement and application.
Keister LA, Stecher C, Aronson B, et al. BMC Public Health. 2021;21:1518.
Constrained diagnostic situations in the emergency department (ED), such as crowding, can impact safe care. Based on multiple years of electronic health record data from one ED at a large U.S. hospital, researchers found that providers were significantly less likely to prescribe opioids during constrained diagnostic situations and less likely to prescribe opioids to high-risk patients or racial/ethnic minorities.
Petrosoniak A, Fan M, Hicks CM, et al. BMJ Qual Saf. 2021;30:739-746.
Trauma resuscitation is a complex, specialized process with a high risk for errors. Researchers analyzed videotapes of in situ simulations to evaluate latent safety events occurring during trauma resuscitation. Themes influencing latent safety events related to physical workspace, mental model formation, equipment, unclear accountability, demands exceeding individuals’ capacity, and task-specific issues.
Jakonen A, Mänty M, Nordquist H. Jt Comm J Qual Patient Saf. 2021;47:572-580.
Checklists have been implemented in a variety of specialties and settings to improve safe patient care. In this study, researchers developed and pilot-tested safety checklists for emergency response driving (ERD) and patient transport in Finland. Semi-structured interviews with paramedics and ERD drivers indicated that the safety checklists improved perceived safety.
Stokke R, Melby L, Isaksen J, et al. BMC Health Serv Res. 2021;21:553.
This article explored the interface of technology and patients in home care. Researchers identified three work processes that contribute to patient safety: aligning people with technologies, being alert and staying calm, and coordinating activities based on people and technology. Topics for future research should include the division of labor on home care shifts, the need for new routines and education in telecare for care workers, and how decisions are made regarding home technology.
Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.
Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.
Race-adjusted decision making tools perpetuate the potential for diagnostic error and care delay. This article examines race correction as a form of bias in health care and discusses efforts to reduce the use of race-adjusted algorithms.
Albutt AK, Berzins K, Louch G, et al. nt J Ment Health Nurs. 2021;30:798-810.
The UK’s National Health System has faced gaps in mental health care delivery affecting patient safety. Interviews with 14 mental health professionals identified several factors associated with patient safety in mental health service settings including safety culture, communication systems, service user factors, service process, and staff workload. Interventions to improve patient safety in mental health settings should be developed with these factors in mind.
Zestcott CA, Spece L, McDermott D, et al. J Racial Ethn Health Disparities. 2021;8:230-236.
Implicit bias can contribute to poor decision-making and lead to poor patient outcomes. This qualitative study found that many healthcare providers have negative implicit attitudes about American Indians, such as implicitly stereotyping American Indians as noncompliant patients. The effect of these implicit attitudes and stereotypes was moderated by self-reported cultural competency and implicit bias training.
Zwaan L, El-Kareh R, Meyer AND, et al. J Gen Intern Med. 2021;36:2943-2951.
Reducing harm related to diagnostic error remains a major focus within patient safety. Based on input from an international group of experts and stakeholders, the authors identified priority questions to advance diagnostic safety research. High-priority areas include strengthening teamwork factors (such as the role of nurses in diagnosis), addressing system factors, and strategies for engaging patients in the diagnostic process.
Zhou Y, Walter FM, Singh H, et al. Cancers (Basel). 2021;13:156.
Delays in cancer diagnosis can lead to treatment delays and patient harm. This study linking primary care and cancer registry data found that more than one-quarter of bladder and kidney cancer patients presenting with fast-tract referral features did not achieve a timely diagnosis. These findings suggest inadequate adherence to guidelines intended to help identify patients with high risk of cancer based on the presence of alarm signs and symptoms.
Kobo-Greenhut A, Sharlin O, Adler Y, et al. Int J Qual Health Care. 2021;33:mzaa151.
Failure mode and effect analysis (FMEA) is used to asses risk in various heath care processes. This study found that an algorithmic prediction of failure modes in healthcare (APFMH) is more effective in identifying hazards and uses fewer resources (time and human resource investment) than traditional FMEA.
Structural racism affects both population and individual health. This article proposes four key areas in which the medical and public health communities can contribute in order to change policy and social norms: documenting the impact of racism on health; improving the collection and availability of race and ethnicity data; turning the lens to themselves; and, acknowledging that structural racism has been challenged by mass social movements.
Keen J, Abdulwahid MA, King N, et al. BMJ Open. 2020;10:e036608.
Health information technology has the potential to improve patient safety in both inpatient and outpatient settings. This systematic review explored the effect of technology networks across health systems (e.g., linking patient records across different organizations) on care coordination and medication reconciliation for older adults living at home. The authors identified several barriers to use of such networks but did not identify robust evidence on their association with safety-related outcomes.
Procaccini D, Rapaport R, Petty BG, et al. Jt Comm J Qual Patient Saf. 2020;46:706-714.
The use of PRN (“as needed”) medications is a common source of medication errors. The authors describe the implementation of staff education and a pediatric intensive care unit (PICU) order set (with predefined PRN orders), which led to increased compliance with Joint Commission medication management standards. The related editorial discusses how investment in human factors and ergonomics can contribute to healthcare quality and safety improvements.
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.
Turner K, Staggs V, Potter C, et al. BMJ Qual Saf. 2020;29:1000-1007.
Fall prevention remains a patient safety priority. This article describes how fall prevention strategies are being implemented and operationalized across 60 hospitals in the United States. While many hospitals employed recommended strategies identified, implementation was suboptimal at times – for example, interdisciplinary fall committees were common but rarely included physicians.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.