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A 65-year-old female with a documented allergy to latex underwent surgery for right-sided Zenker’s diverticulum. Near the conclusion of surgery, a latex Penrose drain was placed in the neck surgical incision. The patient developed generalized urticaria, bronchospasm requiring high airway pressures to achieve adequate ventilation, and hypotension within 5 minutes of placement of the drain. The drain was removed and replaced with a silicone drain. Epinephrine and vasopressors were administered post-operatively and the patient’s symptoms resolved.

Kwok Y-ting, Lam M-sang. BMJ Open Qual. 2022;11:e001696.
Changes in healthcare delivery and care processes as a result of the COVID-19 pandemic have increased the risk for falls. This study explored the impact of the COVID-19 pandemic and the implementation of a fall prevention program (focused on human factors and ergonomics principles) on inpatient fall rates at one hospital in Hong Kong. Findings indicate that fall rates significantly increased from pre-COVID to during the first wave of the pandemic (July-June 2020). The fall prevention program – implemented in July 2020 – led to a reduction of fall rates, but not to pre-pandemic levels.
Hamad DM, Mandell SP, Stewart RM, et al. J Trauma Acute Care Surg. 2022;92:473-480.
By analyzing errors that lead to preventable or potentially preventable deaths in trauma care, healthcare organizations can develop mitigation strategies to prevent those errors from reoccurring. This study classified events anonymously reported by trauma centers using the Joint Commission on Accreditation of Healthcare Organizations Patient Safety Event Taxonomy. Mitigation strategies were most often low-level, person-focused (e.g., education and training).
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.
Randall KH, Slovensky D, Weech-Maldonado R, et al. Pediatr Qual Saf. 2021;6:e470.
Achieving high reliability is an ongoing goal for health care. This survey of 25 pediatric organizations participating in a patient safety collaborative identified an inverse association between safety culture and patient harm, but found that elements of high-reliability, leadership, and process improvement were not associated with reduced patient harm.
Taylor E, Hignett S. Int J Environ Res Public Health. 2021;18:7780.
Informed environmental features, such as the built environment, can improve safety outcomes. The authors propose a theoretic model and matrix (DEEP SCOPE; DEsigning with Ergonomic Principles – Safety as Complexity of the Organization, People, and Environment) intended to synthesize design interventions into a systems-based model using the principles of human factors and ergonomics.
Taylor M, Reynolds C, Jones RM. Patient Safety. 2021;3:45-62.
Isolation for infection prevention and control – albeit necessary – may result in unintended consequences and adverse events. Drawing from data submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers explored safety events that impacted COVID-19-positive or rule-out status patients in insolation. The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related events.

A 61-year-old male was admitted for a right total knee replacement under regional anesthesia. The surgeon – unaware that the anesthesiologist had already performed a right femoral nerve block with 20 ml (100mg) of 0.5% racemic bupivacaine for postoperative analgesia – also infiltrated the arthroplasty wound with 200 mg of ropivacaine. The patient was sedated with an infusion of propofol throughout the procedure.

Farhat A, Al‐Hajje A, Csajka C, et al. J Clin Pharm Ther. 2021;46:877-886.
Several tools have been developed to reduce potentially inappropriate prescribing. This study explored the economic and clinical impacts of two tools, STOPP/START and FORTA (Fit fOR The Aged list). Randomized controlled trials (RCTs) using those tools demonstrated significant clinical and economic impact in geriatric and internal medicine. Due to the low number of RCT studies evaluating these tools, additional studies are warranted.
Isherwood P, Waterson P. J Patient Saf Risk Manag. 2021;26:64-73.
Investigating adverse events and identifying contributing factors is essential to organizational learning and improving patient safety. The authors of this article use three different methodologies – root cause analysis (RCA), human factors analysis classification system (HFACS), and AcciMap (which places emphasis on multiple levels of decision making important to risk management) – to analyze one near miss incident and illustrate how different methodologies generate different systems-level recommendations.
Dryver E, Lundager Forberg J, Hård af Segerstad C, et al. BMJ Qual Saf. 2021;30:697-705.
Checklists are commonly used in surgical and critical care settings to improve patient safety. This multisite study simulation study found that checklists can improve local resuscitation teams’ management of medical crises such as anaphylactic shock and septic shock in emergency departments.
Panda N, Etheridge JC, Singh T, et al. World J Surg. 2021;45:1293-1296.
The World Health Organization (WHO) surgical safety checklist is widely used in surgical settings to prevent errors. This multinational panel representing multiple clinical specialties identified 16 recommendations for checklist content modification and implementation during the COVID-19 pandemic. These recommendations exemplify how the checklist can be adapted to meet urgent and emerging needs of surgical units by targeting important processes and encouraging critical discussions.
Rich RK, Jimenez FE, Puumala SE, et al. HERD. 2020;14:65-82.
Design changes in health care settings can improve patient safety. In this single-site study, researchers found that new hospital design elements (single patient acuity-adaptable rooms, decentralized nursing stations, access to nature, etc.) improved patient satisfaction but did not impact patient outcomes such as length, falls, medication events, or healthcare-associated infections.  

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.

Toccafondi G, Di Marzo F, Sartelli M, et al. Int J Qual Health Care. 2021;33(Supp 1):51-55. 

 

The impact of the COVID-19 pandemic on infection prevention efforts and healthcare-associated infections is unclear. This article discusses how the COVID-19 pandemic has led to adaptations to infection prevention and control and surveillance (IPCS) practices and a human factors and ergonomics perspective in surgery. Leveraging lessons learned from the pandemic, the authors use a human factors perspective to propose an enhanced infection prevention and control approach to prevent surgical site infections. 
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.