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Aljuaid J, Al-Moteri M. J Emerg Nurs. 2022;48:189-201.
Situational awareness is the degree to which perception of a situation matches reality, and the lack of situational awareness can result in decreased patient outcomes. This study measured nurses’ situational awareness immediately after inspection of a resuscitation cart. Importantly, researchers observed significant issues related to readiness preparedness, such as empty oxygen tanks, drained batteries, and equipment failures.
Branch F, Santana I, Hegdé J. Diagnostics (Basel). 2022;12:105.
Anchoring bias is relying on initial diagnostic impression despite subsequent information to the contrary. In this study, radiologists were asked to read a mammogram and were told a random number which researchers claimed was the probability the mammogram was positive for breast cancer. Radiologists' estimation of breast cancer reflected the random number they were given prior to viewing the image; however, when they were not given a prior estimation, radiologists were highly accurate in diagnosing breast cancer.
Koike D, Nomura Y, Nagai M, et al. Int J Qual Health Care. 2020;32:522-530.
Nontechnical skills are gaining interest as one way to enhance surgical team performance and patient safety. In this single-center study, the authors found that a perioperative bundle that introduced nontechnical skills to the surgical team was effective in reducing operative time.   
Abdelhadi N, Drach‐Zahavy A, Srulovici E. J Adv Nurs. 2020;76:2161-2170.
This qualitative study conducted focus groups with 28 registered nurses working in different hospital settings to explore perspectives regarding decision-making and personal or contextual attributes leading to missed nursing care.  Three themes emerged based on the analysis: missed nursing care can result due to scarce resources or nurses’ agency, differences in thinking based on routine or novel situations, and situational factors triggering fluctuations in their awareness (such as difficult patients or the presence of family). The authors suggest that organizational training programs should encourage nurses to identify barriers and facilitators of missed nursing care and approaches to overcome these factors.
Haimi M, Brammli-Greenberg S, Baron-Epel O, et al. BMC Med Inform Decis Mak. 2020;20.
This retrospective mixed-methods study explored patient safety within a pediatric telemedicine triage service by assessing the appropriateness and reasonableness of the diagnosis reached by the online physician. The researchers analyzed a random sample of telephone consultations and conducted qualitative interviews with physicians to obtain their perspectives about factors impacting their reaching diagnosis and deciding on reasonable and appropriate treatment. Analysis of telephone consultations found high levels of diagnosis appropriateness, decision reasonableness and accuracy. Physician interviews revealed six themes for appropriate diagnosis and decision-making: (1) use of intuition, (2) experience, (3) use of rules of thumb and protocols, (4) making shared decisions with parents, (5) considering non-medical factors, and (6) using additional tools such as video chat or digital photos when necessary.
Perea-Pérez B, Labajo-González E, Acosta-Gío AE, et al. J Patient Saf. 2020;16.
Based on malpractice claims data in Spain, the authors propose eleven recommendations to mitigate preventable adverse events in dentistry. These recommendations include developing a culture of safety, improving the quality of clinical records, safe prescribing practices, using checklists in oral surgical procedures, and having an action plan for life-threatening emergencies in the dental clinic.
Kim H-E, Kim HH, Han B-K, et al. The Lancet Digital Health. 2020.
There is increasing interest in the use of artificial intelligence (AI) to improve breast cancer detection. This study developed and validated an AI algorithm using mammography readings from five institutions in South Korea, the United States, and the United Kingdom. The AI algorithm alone showed better diagnostic performance in breast cancer detection compared to radiologists without AI assistance (area under the curve [AUC] of 0.94 vs. 0.81, p<0.0001) or radiologists with AI assistance (0.88; p<0.0001). AI improved performance of radiologists and was better at detecting mass cancers, distortion, asymmetry, or node-negative cancers compared with radiologist alone.
Pourteimour S, Hemmati MalsakPak M, Jasemi M, et al. Pediatr Qual Saf. 2019;4.
This single site study examined the effect of a smartphone messenger app on nursing students’ learning about preventing medication errors in pediatric patients. Researchers concluded that such a tool can reduce medication errors and increase learning among nursing students.
Eslami K, Aletayeb F, Aletayeb SMH, et al. BMC Pediatr. 2019;19:365.
Medication errors are thought to be common in neonatal intensive care units (NICUs). This study compared the incidence of medication errors occurring in two NICUs over a three-month period. Over the study period, there were an average of 3.38 medication errors per patient and three-quarters of neonates experienced at least one error. Preterm neonates experienced medication errors significantly more often than term neonates. Errors in prescription dosage and administration were the most common errors.
Kakemam E, Kalhor R, Khakdel Z, et al. J Adv Nurs. 2019;75:3609-3618.
Staff workload and stress can impact patient safety and increase the risk of an adverse event. A survey of hospital nurses in Iran found that job demands (“role stressors”) and stressors stemming from interpersonal relations were significant predictors of adverse events.
Zhu L, Reychav I, McHaney R, et al. Int J Risk Saf Med. 2019;30:129-153.
Understanding the contributors to adverse events helps to identify ways to prevent future events. This study used natural language processing (NLP) strategies and social network analysis (SNA) to explore the underlying behaviors contributing to adverse events, and suggested institutional-level approaches to reducing these events. 
Fahrni ML, Azmy MT, Usir E, et al. PLoS One. 2019;14:e0219898.
In this prospective study involving 301 older patients admitted to 3 hospitals, researchers used the STOPP and START criteria to identify inappropriate prescribing and adverse drug events. Inappropriate prescribing was detected in 59% of patients and potentially inappropriate medications in 35% of patients. The use of inappropriate medications was associated with an increased odds of an adverse drug event.
Abe T, Tokuda Y, Shiraishi A, et al. Crit Care. 2019;23:202.
This retrospective study sought to determine whether timely diagnosis of the site of infection affected in-hospital mortality for sepsis. Investigators found that patients whose infection site was misdiagnosed on admission had more than twofold greater odds of dying in the hospital compared to those with the correct infection site diagnosed on admission. These results reinforce the importance of correct and timely diagnosis for sepsis outcomes.
Liew TM, Lee CS, Shawn KLG, et al. Ann Fam Med. 2019;17:257-266.
Many older patients experience medication-related harm due to inappropriate prescribing. This meta-analysis found that potentially inappropriate medication prescribing in older patients worsened health-related quality of life and increased emergency department visits and hospitalizations. A WebM&M commentary discussed strategies for safer medication management for older patients.
Sajith SG, Fung D, Chua HC. J Patient Saf. 2021;17:e306-e312.
Trigger tools allow for automated detection of patient harm from electronic health record data. Researchers developed and tested a 25-item trigger tool for mental health settings that identified virtually every adverse event that was found in confirmatory chart review. The authors suggest that this tool may advance safety efforts in inpatient mental health settings.
Tschandl P, Codella N, Akay BN, et al. Lancet Oncol. 2019;20:938-947.
Machine learning may have the potential to improve clinical decision-making and diagnosis. In this study, machine-learning algorithms generally performed better than human experts in accurately diagnosing 7 types of pigmented skin lesions and the top 3 algorithms performed better than the 27 physicians.
Patel S, Robertson B, McConachie I. Anaesthesia. 2019;74:904-914.
Medication administration mistakes can result in serious patient harm. This review explored human factors that contribute to spinal anesthesia administration errors. The authors documented organizational, supervisory, system, and individual factors that contributed to errors. They recommend strategies to prevent such incidents, including the use of double checks and improved labeling practices.
Halperin O, Bronshtein O. Nurse Educ Pract. 2019;36:34-39.
Underreporting of safety events and near misses in the health care setting has been well described and is one of the challenges in using data from incident reporting systems to measure safety. Researchers surveyed nursing students and clinical instructors to identify barriers to reporting and found that fear of negative consequences was a major factor.
Woodham LA, Round J, Stenfors T, et al. PLoS One. 2019;14:e0215597.
Researchers assessed the impact of two different virtual patient models containing error-based scenarios on medical students at six different institutions across three countries. They found that the use of branched decision-making logic did not change students' motivation as compared to a linear virtual patient model without such logic.
Chew KS, van Merrienboer JJG, Durning SJ. BMC Med Educ. 2019;19:18.
Metacognition is an approach to enhance diagnostic thinking. This study used focus groups to assess physicians' and medical students' impressions of a metacognitive diagnostic checklist. Participants found the checklist to be applicable and usable, and the authors conclude that it should be tested in a clinical setting.