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McHale S, Marufu TC, Manning JC, et al. Nurs Crit Care. 2021;Epub Oct 20.
Failure to identify and prevent clinical deterioration can reflect the quality and effectiveness of care. This study used routinely collected emergency event data to identify failure to rescue events at one tertiary children’s hospital. Over a nine-year period, 520 emergency events were identified; 25% were cardiac arrest events and 60% occurred among patients who had been admitted for more than 48 hours. Over the nine-year period, failure to rescue events decreased from 23.6% to 2.5%.
Flowerdew L, Tipping M. Emerg Med J. 2021;38(10):769-775.
This study sought to validate an emergency department (ED) safety questionnaire developed in the United States, and adapted for use in the UK. The survey was validated by 33 patient safety leads and used in a multi-center survey. Analysis highlighted risks and positive factors (e.g., positive safety culture) present in surveyed EDs.
Härkänen M, Haatainen K, Vehviläinen-Julkunen K, et al. Int J Environ Res Public Health. 2021;18(17):9206.
Building on previous research on the use of text mining related to medication administration error incidents, researchers in this study found that artificial intelligence can be used to accurately classify the free text of medication incident reports causing serious or moderate harm, to identify target risk management areas.
Klasen JM, Teunissen PW, Driessen EW, et al. Med Teach. 2021;Epub Oct 13.
Previous research has found that error permission (allowing errors to arise naturally and not preventing them) is a common strategy used in clinical training. This qualitative study with supervising physicians found that decisions to allow residents to fail are often made in the moment and are influenced by the patient, supervisor, trainee, and environmental factors.
Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. J Oncol Pharm Pract. 2021;27(7):1588-1595.
Researchers in this study used healthcare failure mode and effect analysis (HFMEA) to identify and reduce errors during chemotherapy preparation. Nine potential failure modes were identified – wrong label, drug, dose, solvent, or volume; non-sterile preparation; incomplete control; improper packaging or labeling, and; break or spill – and the potential causes and effects. Potential approaches to reduce these failure modes include updating the Standard Operating Procedures (SOPs), implementing a bar code system, and using a weight-based control system.
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.
Hennus MP, Young JQ, Hennessy M, et al. ATS Sch. 2021;2(3):397-414.
The surge of patients during the COVID-19 pandemic forced the redeployment of non-intensive care certified staff into intensive care units (ICU). This study surveyed both intensive care (IC)-certified and non-IC-certified healthcare providers who were working in ICUs at the beginning of the pandemic. Qualitative synthesis identified five themes related to supervision; quality and safety of care; collaboration, communication, and climate; recruitment, scheduling and team composition, and; organization and facilities. The authors provide recommendations for future deployments.
Hyvämäki P, Kääriäinen M, Tuomikoski A-M, et al. J Patient Saf. 2021;Epub Aug 23.
Previous studies have demonstrated health information exchanges (HIE) can improve the quality and safety of care by improving diagnostic concordance and reducing medication errors. This review synthesizes physicians’ and nurses’ perspectives on patient safety related to use of HIE in interorganizational care transitions. Several advantages of and challenges with HIE are detailed.
Mo Y, Eyre DW, Lumley SF, et al. PLoS Med. 2021;18(10):e1003816.
Nosocomial transmission of COVID-19 is an ongoing concern given the pressures faced by hospitals and healthcare workers during the pandemic. This observational study using data from four hospitals in the United Kingdom found that patients with hospital-onset COVID-19 (compared to suspected community-acquired infections) are associated with high risk of nosocomial transmissions to other patients and healthcare workers.
Silverglow A, Johansson L, Lidén E, et al. Scand J Caring Sci. 2021;Epub Aug 24.
Home care settings harbor unique patient safety challenges. This qualitative study identified three themes regarding care providers’ perceptions of providing safe care for frail older adults living at home – the role of the encounter and interaction, the responsibility of the caregiver, and the threat of insufficient organizational resources.
Braverman A. Nurs Manage. 2021;52(9):30-34.
In high-consequence environments, differences of opinion can undermine teamwork and result in operational failure. This article discusses the application of crew resource management (CRM) to the clinical environment. The author outlines steps to translate the aviation CRM experience into the health care domain to improve communication and resolve conflicts in stressful situations.
Renaudin P, Coste A, Audurier Y, et al. Basic Clin Pharmacol Toxicol. 2021;129(6):504-509.
Pharmacists play an essential role in medication safety through practices such as medication reconciliation and best possible medication history. This observational study found that 20% of patients presenting to surgical units at one French hospital over a two-month period had a medication error. Pharmacists intervened and resolved medication errors related to untreated indications, subtherapeutic dosages, and prescriptions without an indication.
Mulac A, Hagesaether E, Granas AG. J Adv Nurs. 2022;78(1):224-238.
Medication dosing errors can lead to serious patient harm. This retrospective study found that the majority of dose calculation errors reported to the Norwegian Incident Reporting System involved intravenous administration such as intravenous morphine. These errors occurred due to lack of proper safeguards to intercept prescribing errors, stress, and bypassing double checks.
Blume KS, Dietermann K, Kirchner‐Heklau U, et al. Health Serv Res. 2021;56(5):885-907.
Nurse staffing levels have been shown to impact patient outcomes. Through an umbrella literature review and expert interviews, researchers developed a list of nurse-sensitive patient outcomes (NSPO). This list provides researchers potential avenues for future studies examining the link between nurse staffing levels and patient outcomes.
O’Dowd E, Lydon S, Lambe KA, et al. Fam Pract. 2021;Epub Sep 20.
Patient complaints can identify opportunities for patient safety improvement. This study explored whether an existing tool for measuring the severity of patient complaints – the Healthcare Complaints Analysis Tool – can effectively analyze complaints specific to general practice. Key issues identified by the study involved relationships (e.g., communication, patient rights) as well as clinical and management issues.
Schlichtig K, Dürr P, Dörje F, et al. Clin Pharmacol Ther. 2021;110(4):1075-1086.
Building on prior research, this study found that medication errors are common in patients starting new oral anticancer therapy. Nearly two-thirds of these medication errors involved concomitantly administered medications (e.g., other prescribed drugs, over-the-counter medications).
Seidl E, Seidl O. J Healthc Risk Manag. 2021;41(2):9-17.
Diagnostic safety is a patient safety priority across all medical specialties. Over a five-year period, researchers found that 15% of patients referred for psychosomatic consultations at one university hospital were misdiagnosed. Misdiagnosis was primarily attributed to availability bias or other biases. Semi-structured interviews with referring physicians highlight the contributing role of physician attitudes and unusual clinical features.
Skoogh A, Hall-Lord ML, Bååth C, et al. BMC Health Serv Res. 2021;21(1):1093.
Improving maternal safety is a priority patient safety issue. Using the Global Trigger Tool, researchers found that nearly three-quarters of adverse events in one labor ward in a Swedish hospital were preventable. Common events included lacerations and anesthesia-related events and often resulted in a prolonged hospital stay.