The PSNet Collection

Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error.

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Institute for Safe Medication Practices and the Just Culture Company. May 6, 2022.

Organizational factors can contribute to the occurrence of patient safety events and how health systems respond to such events. This webinar highlighted lessons learned in the aftermath of a fatal medication error, and strategies to improve patient safety at the organizational level through system design and accountability.

Five-year audit of adherence to an anaesthesia pre-induction checklist.

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Fuchs A, Frick S, Huber M, et al. Anaesthesia. 2022;77:751-762.

Pre-procedure checklists have been shown to improve patient safety but they are still not utilized in all situations. Analysis of five years of airway management checklist use in operating room, non-operating room, and emergency procedures showed increasing adherence to checklist use, but completion varied by time of day, location, and urgency of procedure. Further research into causes for these variations is recommended.

Healthcare Systems Ergonomics and Patient Safety Triennial Conference.

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Delft University of Technology. Faculty Industrial Design Engineering. Delft, The Netherlands, November 2-4, 2022

Learning from the human factors community is a key strategy for system safety improvement. This conference, with the theme of Convergence - Breaking Down Barriers between Disciplines, will present sessions on topics such as patient safety, resilience engineering, and clinical decision making.

"Some version, most of the time": the surgical safety checklist, patient safety, and the everyday experience of practice variation.

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Hammond Mobilio M, Paradis E, Moulton C-A. Am J Surg. 2022;223:1105-1111.

Surgical safety checklists (SSC) have been adopted around the world, but reported compliance rates and use in practice vary widely. This study in one Canadian hospital showed the SSC was used in 82% of Briefings, 76% of Time-Outs, and 22% of Debriefings. Gaps between policy and practice were identified and implications for policy makers, administrators, frontline clinicians, and researchers are discussed.

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Medication/Drug Errors

The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps

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January 7, 2022

A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several different providers (pre-operative nurse, resident physician, attending physician, and anethesiology team) to help prepare her for the procedure. In the OR, the surgical team performed two separate time-outs while the patient was being prepped, placed under general anesthesia, and draped.

Prevention of failure to rescue in obstetric patients: a realist review.

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Bernstein SL, Kelechi TJ, Catchpole K, et al. Worldviews Evid Based Nurs. 2021;18:352-360.

Failure to rescue, the delayed or missed recognition of a potentially fatal complication that results in the patient’s death, is particularly tragic in obstetric care. Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, the authors describe the work system, process, and outcomes related to failure to rescue, and develop intervention theories.

Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples.

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US Food and Drug Administration. October 7, 2021.

Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this updated announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.

The Safety Competencies Framework.

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Ottawa, ON: Canadian Patient Safety Institute; 2008.

This initative defines competency domains for safe health care and outlines educational practices to achieve them. The 2nd edition of the Patient Safety Competencies was released in 2020.

Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery.

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Combs CA, Einerson BD, Toner LE. Am J Obstet Gynecol. 2021;225:b43-b49.

Maternal and newborn safety is challenged during cesarean delivery due to the complexities of the practice. This guideline recommends specific checklist elements to direct coordination and communication between the two teams engaged in cesarean deliveries. The guideline provides a sample checklist and steps for its implementation.

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Maternal Safety

Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected

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August 25, 2021

A seven-year-old girl with esophageal stenosis underwent upper endoscopy with esophageal dilation under general anesthesia. During the procedure, she was fully monitored with a continuous arterial oxygen saturation probe, heart rate monitors, two-lead electrocardiography, continuous capnography, and non-invasive arterial blood pressure measurements.

FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing.

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Silver Springs, MD: US Food and Drug Administration: June 25, 2021.

Incomplete reprocessing of reusable flexible endoscopes can result in nosocomial infection. This announcement highlights recent guidance to improve the safe reuse of bronchoscopes with a focus on scope design, sterile processing, and infection control program management.

Patient safety in dermatology: a ten-year update.

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Patel J, Otto E, Taylor JS, et al. Dermatol Online J. 2021;27(3).

In an update to their 2010 article, this review’s authors summarized the patient safety literature in dermatology from 2009 to 2020. In addition to topics covered in the 2010 article, this article also includes diagnostic errors related to telemedicine, laser safety, scope of practice, and infections such as COVID-19. The authors recommend further studies, and reports are needed to reduce errors and improve patient safety.

An Inadvertent Bolus of Norepinephrine.

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May 26, 2021

A 64-year-old woman was admitted to the hospital for aortic valve replacement and aortic aneurysm repair. Following surgery, she became hypotensive and was given intravenous fluid boluses and vasopressor support with norepinephrine. On postoperative day 2, a fluid bolus was ordered; however, the fluid bag was attached to the IV line that had the vasopressor at a Y-site and the bolus was initiated.

Implementation of a parent-centered approach to the preinduction checklist in pediatric surgery.

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Arshad SA, Ferguson DM, Garcia EI, et al. J Surg Res. 2021;257:455-461.

Engaging patients and families is an important strategy in ensuring safe health care delivery. In this prospective, observational study, use of a parent-centered script did not improve parent engagement during the preinduction checklist and resulted in an expected decline in checklist adherence.

FDA updates vinca alkaloid labeling for preparation in intravenous infusion bags only.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 15, 2021.

Vinca alkaloid misadministration is a persistent problem that results in patient harm and death. This alert raises awareness of label changes that aim to mitigate accidental spinal administration of the high-alert chemotherapy agent by supporting infusion bag administration only.

The effect of blue-enriched lighting on medical error rate in a university hospital ICU.

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Chen Y, Broman AT, Priest G, et al. Jt Comm J Qual Saf. 2021;47:165-175.

Fatigue among health care workers can increase risk of errors. This study posited that blue-enriched light could promote alertness and attention and thereby reduce medical errors in the ICU; however, the authors did not identify any effect of this intervention on error rates.

How does the environment influence consumers' perceptions of safety in acute mental health units? A qualitative study.

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Cutler NA, Halcomb E, Sim J, et al. J Clin Nurs. 2021;30:765-772.

Patient safety is an emerging focus within the mental health field. Using qualitative methods, the authors explored environmental influences on patient perceptions of safety in acute mental health settings. Participants highlighted the importance of staff presence, privacy, feeling safe from other patients, and access to meaningful activities (such as meaningful time alone or structured activities).

An implementation science approach to promote optimal implementation, adoption, use, and spread of continuous clinical monitoring system technology.

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Dykes PC, Lowenthal G, Faris A, et al. J Patient Saf. 2021;17:56-62.

Failure to rescue – the lack of adequate response to patient deterioration – has been associated with adverse patient outcomes, particularly in acute care settings. This article describes two health systems’ efforts to implement in-hospital Clinical Monitoring System Technology (CMST) which positively impacted failure-to-rescue events. The authors identified barriers and facilitators to CMST use, which informed the development of an implementation toolkit addressing readiness, implementation, patient/family introduction, champions, and troubleshooting.

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