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Pueyo-López C, Sánchez-Cuervo M, Vélez-Díaz-Pallarés M, et al. J Oncol Pharm Pract. 2021;27:1588-1595.
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.
Schlichtig K, Dürr P, Dörje F, et al. Clin Pharmacol Ther. 2021;110:1075-1086.
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).
Huynh I, Rajendran T. BMJ Open Qual. 2021;10:e001363.
Unintentional therapeutic duplication can lead to life-threatening complications. As part of a quality improvement project on a surgical ward, staff were educated about the risks of therapeutic duplication and strategies to decrease it. After one month of education and reminders, the rate of therapeutic duplication decreased by more than half.
van der Zanden M, de Kok L, Nelen WLDM, et al. Diagnosis (Berl). 2021;8:333-339.
Endometriosis is a common clinical condition that is often subject to missed or delayed diagnosis. This qualitative study explored patients’ perspectives on the diagnostic process of endometriosis. Findings suggest that the diagnosis of endometriosis is hindered by delayed consultation, inadequate understanding and appraisal of symptoms by general practitioners, and inadequate communication between patients and providers.

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.
Danielis M, Destrebecq A, Terzoni S, et al. Dimens Crit Care Nurs. 2021;40:186-191.
While the effectiveness of medical emergency teams (MET) has been widely researched, critical incidents that occur during the response have not received the same attention. This retrospective study analyzed critical incidents that occurred during MET responses over a five-year period. They mainly occurred due to lack of compliance with protocols and lack of available supplies. Educational and organizational strategies may be effective in reducing critical events during MET.
Henn P, O’Tuathaigh C, Keegan D, et al. J Patient Saf. 2021;17:e155-e160.
Hearing impairment can lead to misunderstanding of a patient’s health condition, treatment, or follow up care. Patients with hearing loss frequently misheard, misunderstood, or misinterpreted information given to them from a nurse or physician in both hospital and ambulatory settings. Health systems and clinicians should find ways to identify patients with hearing loss and develop alternate methods to communicate, such as visual aids, quiet environments, and lip reading communication.
Cattaneo D, Pasina L, Maggioni AP, et al. Drugs Aging. 2021;38:341-346.
Older adults are at increased risk of hospitalization due to COVID-19 infections. This study examined the potential severe drug-drug interactions (DDI) among hospitalized older adults taking two or more medications at admission and discharge. There was a significant increase in prescription of proton pump inhibitors and heparins from admission to discharge. Clinical decision support systems should be used to assess potential DDI with particular attention paid to the risk of bleeding complications linked to heparin-based DDIs.
Dürr P, Schlichtig K, Kelz C, et al. J Clin Oncol. 2021;39:1983-1994.
Patients taking oral anti-cancer drugs may experience severe side effects and medication errors. In this randomized controlled study, patients taking oral chemotherapy drugs were randomized to receive usual care (control) or additional intensive pharmacological/pharmaceutical care (intervention). Patients in the intervention group reported considerably fewer medication errors and side effects and increased treatment satisfaction.
Royal College of Obstetricians and Gynaecologists.
This organization highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm. The reporting initiative closed in 2021 after presenting its final report. Investigations in this area will now be undertaken by the Healthcare Safety Investigation Branch in England.
Mitchell G, Porter S, Manias E. J Adv Nurs. 2021;77:899-909.
Oral chemotherapy regimens are complex and may lead to severe adverse drug events. Through ethnographic research, the authors found that the two most important factors in ensuring optimal management of oral chemotherapy are (1) early recognition and appropriate response to side effects and (2) maintenance of safe and effective medication communication.
Hensgens RL, El Moumni M, IJpma FFA, et al. Eur J Trauma Emerg Surg. 2020;46:1367-1374.
Missed injuries and delayed diagnoses are an ongoing problem in trauma care. This cohort study conducted at a large trauma center found that inter-hospital transfer of severely injured patients increases the risk of delayed detection of injuries. For half of these patients, the new diagnoses led to a change in treatment course. These findings highlight the importance of clinician vigilance when assessing trauma patients.
Chaudhry H, Nadeem S, Mundi R. Clin Orthop Relat Res. 2021;479:47-56.
The COVID-19 pandemic has dramatically increased the use of telehealth across various medical specialties.This systematic review did not identify any differences in patient or surgeon satisfaction or patient-reported outcomes with telehealth for orthopedic care delivery as compared to in-person visits.However, the authors note that the included studies did not adequately capture or report safety endpoints, such as complications or missed diagnoses.
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.  
Ruutiainen HK, Kallio MM, Kuitunen SK. Eur J Hosp Pharm. 2021;28:e151-e156.
Automated drug dispensing systems can reduce medication dispensing and administration errors.  However, this study found that medication automated dispensing cabinets ADCs)in one hospital frequently contained look-alike, sound-alike (LASA) medications, which may increase the risk for medication error.
Vinther S, Bøgevig S, Eriksen KR, et al. Basic Clin Pharmacol Toxicol. 2020;128:542-549.
Older adults living in long-term care facilities are at increased risk for medication errors. This cohort study examined nursing home residents exposed to medication errors and found that poison control consultations can assist nursing home staff in qualifying risk assessment and potentially reduce hospital admissions.
Kannampallil T, Lew D, Pfeifer EE, et al. BMJ Qual Saf. 2021;30:755-763.
Prior research has found that intraoperative anesthesia handovers can increase patient morbidity and mortality. However, this retrospective cohort study, focused on pediatric surgical patients treated, found that intraoperative anesthesia handovers were not associated with adverse postoperative outcomes.  
Kozasa EH, Lacerda SS, Polissici MA, et al. Front Psych. 2020;11:570786.
Situational awareness during critical incidents is a key component of teamwork. This study found that a mutual care training can increase situational awareness for healthcare workers and consequently improve mental health and well-being before and during the COVID-19 pandemic.
Pryce A, Unwin M, Kinsman L, et al. Int Emerg Nurs. 2020;54:100956.
Emergency department (ED) overcrowding and prolonged ED stays can lead to adverse patient outcomes. This study examined patient flow bottlenecks in the ED and several factors posing risks to patient safety, such as prolonged time to triage and use of makeshift spaces (which may have inadequate staffing allocations or lack necessary equipment).