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Fakih MG, Bufalino A, Sturm L, et al. Infect Control Hosp Epidemiol. 2021;43:26-31.
Central line-associated blood steam infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) prevention were an important part of patient safety prior to the COVID-19 pandemic. This study compared CLABSI and CAUTI rates in 78 hospitals during the 12-month period prior to the pandemic and the first 6 months of the pandemic. CLABSI rates increased by 51% during the pandemic period, mainly in the ICU. CAUTI rates did not show significant changes.
Walton E, Charles M, Morrish W, et al. J Patient Saf. 2022;18:e620-e625.
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.
Molina RL, Benski A-C, Bobanski L, et al. Implement Sci Commun. 2021;2:76.
Checklists are widely used to improve patient safety, including reductions in catheter-related bloodstream infections and surgical morbidity and mortality. This study focuses on implementation of the 2015 World Health Organization Safe Childbirth Checklist (SCC) which aims to prevent maternal and neonatal morbidity and mortality. Twenty-nine participants from fifteen countries with SCC experience completed a survey and twelve were interviewed. Most reported adapting the SCC for their local setting and a wide variety of implementation strategies were used.
Liu LQ, Mehigan S. AORN J. 2021;114:159-170.
Surgical safety checklists (SSC) have been shown to improve outcomes, but effective implementation remains a challenge. This systematic review evaluated the effectiveness of interventions to increase compliance with the World Health Organization’s SSC for adult surgery. Interventions generally fell into one of four categories: modifying the method of SSC delivery, integrating or tailoring the tool for local context, promoting awareness and engagement, and managing organizational policy. Study findings suggest that all approaches resulted in some improvement in compliance.
Kakemam E, Chegini Z, Rouhi A, et al. J Nurs Manag. 2021;29:1974-1982.
Clinician burnout, characterized by emotional exhaustion, depersonalization, and decreased sense of accomplishment, can result in worse patient safety outcomes. This study explores the association of nurse burnout and self-reported occurrence of adverse events during COVID-19. Results indicate higher levels of nurse burnout were correlated with increased perception of adverse events, such as patient and family verbal abuse, medication errors, and patient and family complaints. Recommendations for decreasing burnout include access to psychosocial support and human factors approaches.
Mahadevan K, Cowan E, Kalsi N, et al. Open Heart. 2020;7.
Distractions and interruptions are common during delivery of health care. In this evaluation of 194 cardiac catheterization procedures at a single hospital, the authors found that fewer than half of all procedures were completed without interruption or distraction. The authors propose several actions such as the use of a ‘sterile cockpit’ to reduce distractions and improve patient safety.

La Regina M, Tanzini M, Venneri F, et al for the Italian Network for Health Safety. Dublin, Ireland: International Society for Quality in Health Care; 2021.

The COVID-19 pandemic is a rapidly evolving situation that requires a system orientation to diagnosis, management and post-acute care to keep clinicians, patients, families and communities safe. This set of recommendations is anchored on a human factors approach to provide overarching direction to design systems and approaches to respond to the virus. The recommendations focus on team communication and organizational culture; the diagnostic process; patient and family engagement to reduce spread; hospital, pediatric, and maternity processes and treatments; triage decision ethics; discharge communications; home isolation; psychological safety of staff and patients, and; outcome measures. An appendix covers drug interactions and adverse effects for medications used to treat this patient population. The freely-available full text document will be updated appropriately as Italy continues to respond, learn and amend its approach during the outbreak.

National Alert Network for Serious Medication Errors. Bethesda, MD: American Society of Health-System Pharmacists and Institute for Safe Medication Practices. National Alert Network. September 9, 2020.

This announcement highlights container confusion as a contributing factor for accidental spinal injection of tranexamic acid. Storage, purchase, and preparation recommendations are shared to minimize errors with this medication.
Smalley CM, Willner MA, Muir MKR, et al. Am J Emerg Med. 2020;38:1647-1651.
This study assessed the impact of electronic health record (EHR) interventions to standardize opioid prescribing practices across a large health system. Interventions included (1) deleting clinician preference lists, (2) default dose, frequency, and quantity, (3) standardizing formularies, and (4) dashboards with current opioid prescribing practices. In the 12 months after implementation, there was a decrease in the rate of opioid prescriptions overall, prescriptions exceeding three days, prescriptions exceeding prespecified morphine equivalent doses, and non-formulary prescriptions.
Rainbow JG, Drake DA, Steege LM. West J Nurs Res. 2020;42:332-339.
This study explored the relationships between nurse fatigue, burnout, psychological well-being, team vitality, and patient safety, and the role of presenteeism as a potential mediator. Authors found strong relationships between workplace influences and job-stress presenteeism, and between job-stress presenteeism and patient safety outcomes, including lower rates of event reporting and perceptions of patient safety.

US Health and Human Services Office of the Assistant Secretary for Preparedness and Response’s Technical Resources, Assistance Center, & Information Exchange; US Health and Human Services/FEMA COVID-19 Healthcare Resilience Task Force. June 2, 2020.

Health systems are rapidly adjusting processes to successfully respond to COVID-19 crisis demands. This webinar featured tactics used and discussed initiative results to inform continued improvement. The speaker roster included Jeff Brady, MD and Rollin (Terry) Fairbanks, MD.  
Wooldridge AR, Carayon P, Hoonakker P, et al. App Ergon. 2020;85:103059.
Care transitions increase the risk of patient safety events, and pediatric patients are particularly vulnerable. This study used the Systems Engineer Initiative for Patient Safety approach to analyze care transitions, identify system barriers and solutions to guide efforts towards improving care transitions. Nine dimensions of system barriers and facilities in care transitions were identified: anticipation; ED decision making; interacting with family; physical environment; role ambiguity; staffing/resources; team cognition; technology, and; characteristics of trauma care.  Understanding these barriers and facilitators can guide future endeavors to improve care transitions.
Long E, Barrett MJ, Peters C, et al. Pediatric Anesthesia. 2020;30.
Intubation occurring outside the operating room (OR) is rare but associated with life-threatening adverse events. This review provides an overview of situational, physiological and anatomical contributors to intubation of children outside of ORs; situational challenges – such as human factors or unfamiliar equipment – are most common. Potential solutions to reduce intubation-related adverse events and improve patient safety are discussed, such as systems‐based changes, including a shared mental model, standardization in equipment and its location, checklist use, multi‐disciplinary team engagement and training in the technical and nontechnical aspects of non‐operating room intubation, debrief post–real and simulated events, and regular audit of performance.
Yeh J, Wilson R, Young L, et al. J Nurs Care Qual. 2019.
Prior research has found that nonactionable alarms are common and contribute to alarm fatigue among providers in intensive care units. This single center study employed an interprofessional team-based approach to adjust the default thresholds for arrhythmias and specific parameters such as oxygen saturation, which resulted in a nearly 47% reduction in nonactionable alarms over a two-week period.
Erich J.
Air transport service combines risks associated with both aviation and prehospital trauma care. This article discusses the role of human factors in this fast-paced care environment. The author encourages efforts to reduce risks through policy change, purchasing the latest safety equipment, and empowering staff to decline calls when conditions are unsafe.

ISMP Medication Safety Alert! Acute Care Edition. November 1, 2018;23:1-5. November 15, 2018;23:1-5.

Errors in the administration of intravenous medications can result in patient harm. This set of articles discusses the results of a nationwide IV push medication survey. The first article reviews unsafe practices in care delivery as defined by inpatient clinicians. The second article recommends ways to improve practice such as assessment of current practices, use of prefilled syringes, and heightened attention to effective labeling.
Increased urgency to prevent maternal mortality has uncovered various factors that diminish safety. This newsletter article reports on incidents involving the accidental misuse of epidural analgesia and intravenous antibiotics in labor and delivery care, describes contributing factors (e.g., health technology missteps, barcoding mistakes, and look-alike medications), and offers improvement strategies to mitigate harm.
Kliff S, Pinkerton B, Weinberger J, Drozdowska A. Vox. October 23, 2017.
This audio segment discusses two incidents involving pediatric patient harm associated with central line use and highlights successful reduction of central line infections after investigation, standardization, and checklist use in many hospitals.