De Cassai A, Negro S, Geraldini F, et al. PLoS One. 2021;16(9):e0257508.
Inattentional blindness occurs when individuals miss an unexpected event due to competing attentional tasks. This study asked anesthesiologists to review the anesthetic management of five simulated cases, one of which included the image of a gorilla in the radiograph, to evaluate inattentional blindness. Only 4.9% of social media respondents reported an abnormality, suggesting that inattentional blindness may be common; the authors suggest several strategies to reduce this error.
Manias E, Street M, Lowe G, et al. BMC Health Serv Res. 2021;21(1):1025.
This study explored associations between person-related (e.g., individual responsible for medication error), environment-related (e.g., transitions of care), and communication-related (e.g., misreading of medication order) medication errors in two Australian hospitals. The authors recommend that improved communication regarding medications with patients and families could reduce medication errors associated with possible or probable harm.
Urban D, Burian BK, Patel K, et al. Ann Surg. 2021;2(3):e075.
The WHO surgical safety checklist has been implemented in healthcare systems around the world. Survey responses from 2,032 surgical team members from high-income countries suggest that most respondents perceive the checklist as enhancing patient safety, but that not all team members are engaging with its use or feel confident in their role in the checklist process.
Alanazi FK, Sim J, Lapkin S. Nurs Open. 2022;9(1):30-43.
Nurse attitudes towards patient safety culture have shown to impact missed nursing care, iatrogenic harm, and other adverse events. This review synthesizes research on nurses’ safety attitudes and subsequent impact on patient outcomes. While most data on adverse events was self-reported, nurses indicated an improved safety culture resulted in fewer reported adverse events. Nurse managers can play an important role in improving patient safety culture and outcomes in their hospital units.
Speaking up about concerns is essential to improving safety, but prior research has found that many healthcare workers do not feel comfortable speaking up. In this study, staff members from a disability healthcare organization in Australia responded to a questionnaire regarding organizational identification and culture of safety. Findings highlight the importance of organizational identification and management commitment to safety and psychological safety in promoting speaking up behaviors.
Leggat SG, Balding C, Bish M. J Health Org Manag. 2021;35(5):550-560.
Hospital leaders are essential partners to help establish and sustain a culture of safety. This longitudinal study of Australian hospitals found that hospital leadership and clinical leaders primarily relied on staff to ensure patient safety, rather than relying on systems and processes to prevent errors.
Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478(6):1179-1185.
Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.
Korenstein D, Harris RP, Elshaug AG, et al. J Gen Intern Med. 2021;36(7):2105-2110.
Provider and patient underestimation of harms of tests and treatments may lead to over treatment. This article presents seven domains of harm of tests and treatment which warrant comprehensive research: (1) physical impairment, (2) psychological distress, (3) social disruption, (4) disruption in connection to healthcare, (5) labeling, (6) financial impact, and (7) treatment burden. Research is especially important in vulnerable patient populations.
Bryant J, Carey M, Sanson-Fisher R, et al. J Patient Saf. 2021;17(5):e387-e392.
When an error or adverse event occurs, patients and families want to be informed. In this study of oncology patients, more than one quarter perceived an adverse event had occurred. While most were informed soon after the event occurred and given an explanation, fewer than half were given information on how to move forward with a complaint if they wished. Regular communication between patients and providers about actual or perceived adverse events may decrease the risk of it happening again.
Gillespie BM, Harbeck EL, Kang E, et al. J Patient Saf. 2021;17(5):e448-e454.
Nontechnical skills such as teamwork and communication can influence surgical performance. This Australian hospital implemented a team training program for surgical teams focused on improving individual and shared situational awareness which led to improvements in nontechnical skills.
Transgender and nonbinary individuals may delay or avoid seeking necessary healthcare due to fears of discrimination. This systematic review of qualitative studies of the perspectives of transgender youths identified six major themes regarding their experiences with accessing healthcare, including fear, vulnerability, and systemic barriers. The authors recommend several strategies to improve access to healthcare for transgender individuals.
Small K, Sidebotham M, Gamble J, et al. Midwifery. 2021;102:103074.
Health information technologies intended to reduce patient harm may have unintended consequences (UC). Midwives describe the unintended consequences of central fetal monitoring technology. These consequences included potential loss of patient trust in the midwife, changes in clinical practice, and increased documentation during labor. The authors recommend reevaluation of use of central fetal monitoring due to potential UC without demonstrating improvements in maternal safety.
In this retrospective study, researchers examined patient records to describe patient harm occurring in primary care settings in New Zealand. The majority of harms were minor; 4.5% of harms were considered severe. Nearly 82% of non-fatal harms were considered not preventable and generally arose from routine care.
Scott IA, Hubbard RE, Crock C, et al. Intern Med J. 2021;51(4):488-493.
Sound critical thinking skills can help clinicians avoid cognitive biases and diagnostic errors. This article describes three critical thinking skills essential to effective clinical care – clinical reasoning, evidence-informed decision-making, and systems thinking – and approaches to develop these skills during clinician training.
Adie K, Fois RA, McLachlan AJ, et al. Br J Clin Pharmacol. 2021;87(12):4809-4822.
Medication errors are a common cause of patient harm. This study analyzed medication incident (MI) reports from thirty community pharmacies in Australia. Most errors occurred during the prescribing stage and were the result of interrelated causes such as poor communication and not following procedures/guidelines. Further research into these causes could reduce medication errors in the community.
Zaidi AS, Peterson GM, Bereznicki LRE, et al. Ann Pharmacother. 2021;55(4):530-542.
Prior research has found that polypharmacy among elderly patients with dementia is associated with greater risk of functional decline. This meta-analysis of five studies concluded that exposure to potentially inappropriate medications (PIM) was not associated with either mortality or hospitalization for patients with cognitive impairment.
Le Cornu E, Murray S, Brown EJ, et al. J Med Radiat Sci. 2021;68(4):356-363.
Use of health information technology (HIT) can improve care but also lead to unexpected patient harm. In this analysis of incidents and near misses in radiation oncology, a major change in the use of the electronic health record (EHR) led to an increase in reported incidents and near misses. Leaders and HIT professionals should be aware of potential issues and develop a plan to minimize risk prior to major departmental changed including EHR changes.
Medication safety, particularly among older adults who may have complex medication regimens, is an ongoing safety concern. This study explored medication safety behaviors among young-old (65-74 years), middle-old (75-84 years) and old-old (>85 years) adults. The authors found that older adults are willing to engage in medication safety behaviors, but that preferred behaviors (e.g., verbal behaviors, self-administering medication, reviewing medication charts) differed among the age groups.
Wu F, Dixon-Woods M, Aveling E-L, et al. Soc Sci Med. 2021;280:114050.
Reluctance of healthcare team members to speak up about concerns can hinder patient safety. The authors conducted semi-structured interviews with 165 participants (health system leadership, managers, healthcare providers, and staff) about policies, practice, and culture around voicing concerns related to quality and safety. Findings suggest that both formal and informal hierarchies can undermine the ability and desire of individuals to speak up, but that informal organization (such as personal relationships) can motivate and support speaking up behaviors.
Hada A, Coyer F. Nurs Health Sci. 2021;23(2):337-351.
Safe patient handover from one nursing shift to the next requires complete and accurate communication between nurses. This review aimed to identify which nursing handover interventions result in improved patient outcomes (i.e., patient falls, pressure injuries, medication administration errors). Interventions differed across the included studies, but results indicate that moving the handover to the bedside and using a structured approach, such as Situation, Background, Assessment, Recommendation (SBAR) improved patient outcomes.
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