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.
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%.
Walton E, Charles M, Morrish W, et al. J Patient Saf. 2021;Epub Sep 28.
Dialysis is a common procedure that carries risks if not performed correctly. This study analyzed dialysis-related bleeding events reported to the Veterans Health Administration Patient Safety Authority over an 18-year period. The analysis identified four areas of focus to reduce bleeding events – (1) the physical location and equipment used, (2) staff commitment to standardization and attention to detail (to reduce unwitnessed bleeding events), (3) mental status of the patient, and (4) the method for hemodialysis delivery.
Bekes JL, Sackash CR, Voss AL, et al. AANA J. 2021;89(4):319-324.
Pediatric medication errors during anesthesia can lead to significant harm and are largely preventable. This review identifies several themes around medication errors including dosing and incorrect medication. Successful error reduction strategies, such as standardized labeling and pre-filled syringes, are also described.
Chaker A, Omair I, Mohamed WH, et al. Am J Health Syst Pharm. 2021;Epub Oct 5.
The Institute for Safe Medication Practices recommends compounding pharmacies use technology and automation to improve patient safety. Researchers assessed the workflow and workforce requirements of one hospital’s sterile preparation center (SPC) following implementation of these recommendations. The average time to prepare each type of medication was used to determine pharmacy staffing workforce requirements.
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.
Galatzan BJ, Carrington JM. Res Nurs Health. 2021;44(5):833-843.
During handoffs, nurses are exposed to a variety of interruptions and distractions which may lead to cognitive overload. Using natural language processing, researchers analyzed ten audio-recorded change of shift handoffs to estimate the cognitive load experienced by nurses. Nurses’ use of concise language has the potential to decrease cognitive overload and improve patient outcomes.
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.
Sharma AE, Huang B, Del Rosario JB, et al. BMJ Open Qual. 2021;10(3):e001421.
Patients and caregivers play an essential role in safe ambulatory care. This mixed-methods analysis of ambulatory safety reports identified three themes related to patient and caregivers factors contributing to events – (1) clinical advice conflicting with patient priorities, (2) breakdowns in communication and patient education contributing to medication adverse events, and (3) the fact that patients with disabilities are vulnerable to due to the external environment.
Health care disparities emerging as a core patient safety issue. This alert introduces strategies to align organizational and patient safety strategic goals, such as collection and analysis of community-level performance data, adoption of diversity and inclusion as a precursor to improvement, and development of business cases to support inequity reduction initiatives.
Moy E, Hausmann LRM, Clancy CM. Am J Med Qual. 2022;37(1):81-83.
Shortcomings in health equity represent systemic weaknesses in health care. This commentary suggests that actions to reduce disparities be added to the components of high reliability organizations (HRO) to facilitate an expansion of the HRO concept to address the threat to patient safety that inequity represents.
Sotto KT, Burian BK, Brindle ME. J Am Coll Surg. 2021;233(6):794-809.e8.
The World Health Organization (WHO) Surgical Safety Checklist has been implemented in healthcare systems around the world. This systematic review and thematic analysis concluded that the surgical safety checklist positively impacts clinical outcomes (surgical outcomes and mortality), process measures, team dynamics, and communication, as well as safety culture. The authors note that the checklist was negatively associated with efficiency and workload; included studies often noted that checklist users felt the checklist slowed down processes within the operating room
Simpson M, Kovach CR. Res Gerontol Nurs. 2021;14(6):293-304.
This prospective study explored iatrogenic events emerging among older adults in one post-acute care hospital. Researchers found that most new problems were exacerbations of preexisting conditions rather than problems stemming from the primary reason for hospitalization. Findings indicate risk factors such as comorbidities or functional level may not be useful in determining the likelihood of new problems or iatrogenic events during post-acute rehabilitation.
Debriefing is an important strategy for learning about and making improvements in individual, team, and system performance. It is one of the central learning tools in simulation training and is also recommended after significant clinical events.
Burden AR, Potestio C, Pukenas E. Adv Anesth. 2021;39:133-148.
Handoffs occur several times during a perioperative encounter, increasing the risk of communication errors. Structured handoffs, such as situation-background-assessment-recommendation (SBAR) and checklists, have been shown to improve communication between providers during anesthesia care. The authors discuss how these tools and other processes can improve shared understanding of effective handoffs.
Krishnan S, Wheeler KK, Pimentel MP, et al. J Healthc Risk Manag. 2021;Epub Oct 28.
Incident reporting systems are used to detect patient safety concerns and determine potential causes and opportunities for improvements. In the perioperative setting of one hospital, insufficient handoffs were the most common event type in the “coordination of care” category. Use of structured handoffs is recommended to improve communication and patient safety.
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.
McNiven B, Brown AD. Jt Comm J Qual Patient Saf. 2021;47(12):809-813.
Errors and near misses reported via incident reporting systems can highlight emerging patient safety concerns; however, rates of reporting remain low. In this comparison study of web-based and interactive voice response systems (IVRS), the mean number of reports was higher for IVRS and length of time to complete the report was lower.
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.
Robinson-Lane SG, Sutton NR, Chubb H, et al. J Am Med Dir Assoc. 2021;22(11):2245-2250.
The COVID-19 pandemic has exacerbated racial and ethnic disparities in healthcare. This study used registry data to examine racial and ethnic disparities in post-discharge outcomes among patients hospitalized with COVID-19. Findings indicate that Black patients may be more vulnerable to COVID-19-related complications (e.g., higher 60-day readmission rates) and extended recovery periods (e.g., longest delays in returning to work).
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