Riskin A, Bamberger P, Erez A, et al. Jt Comm J Qual Patient Saf. 2019;45:358-367.
Prior studies have demonstrated that rude behavior undermines patient safety. This study used a smartphone application to collect reports of rudeness directed toward nurses. These data were analyzed in conjunction with the hospital's hand hygiene and medication protocol compliance data as well as adverse event reports to determine if rudeness affected these safety outcomes. Participants also reported whether rudeness incidents influenced their cognition or their teamwork. Although rudeness was associated with worse self-reported cognition and teamwork, investigators did not observe differences in reported adverse events or changes in hand hygiene or medication protocol adherence related to rudeness exposure. A past PSNet perspective discussed how organizations are seeking to rehabilitate persistently disruptive clinicians.
Rönnerhag M, Severinsson E, Haruna M, et al. J Adv Nurs. 2019;75:585-593.
Inadequate communication in obstetrics can compromise safety. In this qualitative study, researchers conducted focus groups of multidisciplinary teams including obstetricians, midwives, and nurses working in a single maternity ward to examine their perceptions of adverse events during childbirth. Analysis of data collected suggests that support for high-quality interprofessional teamwork is important for safe maternity care.
Einav Y, Gopher D, Kara I, et al. Chest. 2010;137:443-9.
Improving perioperative safety requires optimal communication within the surgical team; however, classic studies have shown that teamwork in the operating room is often suboptimal. This study successfully improved communication and safety through creation of a structured preoperative briefing protocol for gynecologic and orthopedic procedures. The protocol required discussion of critical operative elements between the surgeons, anesthesiologists, and nurses prior to surgery. Checklists have been remarkably successful at reducing perioperative adverse events, and this protocol incorporated some elements of previously published perioperative checklists and The Joint Commission's Universal Protocol. However, the protocol used in this study focused on creating shared situational awareness among all team members, and did not explicitly mandate specific steps as in a checklist. An accompanying editorial discusses the cultural challenges that have accompanied attempts to improve surgical safety.
This article discusses computerized physician order entry implementation in US and Asian hospital systems and provides insight into selecting a system and achieving team commitment to the development process.
The investigators used a simulated scenario to analyze communication problems among nursing teams that led to medication errors. They discuss the differences between student and nurse groups, concluding that as service years increase, nurses are less likely to explain and confirm medication requests.
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