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Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals.

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Washington, DC: Leapfrog Group; July 2022.

Diagnostic safety is beginning to be established as a systemic, rather than solely an individual performance issue. This report recommends strategies that support systemic work toward diagnostic excellence and selected implementation stories that illustrate success. It is a part of a larger initiative devoted to the improvement of organizational and team activities in tandem with clinical processes to minimize the impact of human error on diagnosis.

Nurses' harm prevention practices during admission of an older person to the hospital: a multi-method qualitative study.

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Redley B, Douglas T, Hoon L, et al. J Adv Nurs. 2022;Epub Jul 7.

Frontline care providers such as nurses play an important role in reducing preventable harm. This study used qualitative methods (direct observation and participatory workshops) to explore nurses’ experiences implementing harm prevention practices when admitting an older adult to the hospital. Researchers identified barriers (e.g., lack of resources, information gaps) and enablers (e.g., teamwork, reminders) to harm prevention during the admission process.

The effectiveness of improving healthcare teams' human factor skills using simulation-based training: a systematic review.

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Abildgren L, Lebahn-Hadidi M, Mogensen CB, et al. Adv Simul (Lond). 2022;7:12.

Simulation is becoming more common in healthcare education programs, but often focuses on in-hospital, skills-based training aimed at developing team human factors skills. This systematic review included 72 studies from 2004-2021 that included human factors skills with a variety of different designs, types of training interventions, and assessment tools and methods. The authors concluded that simulation-based training was effective in training teams in human factors skills; additional work is needed on the retention and transfer of those skills to practice.

From COVID-19 pandemic to patient safety: a new "spring" for telemedicine or a boomerang effect?

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De Micco F, Fineschi V, Banfi G, et al. Front Med (Lausanne). 2022;9:901788.

The COVID-19 pandemic led to a significant increase in the use of telehealth. This article summarizes several challenges that need to be addressed (e.g., human factors, provider-patient relationships, structural, and technological factors) in order to support continuous improvement in the safety of health care delivered via telemedicine.

Can the standard configuration of a cardiac monitor lead to medical errors under a stress induction?

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Dzisko M, Lewandowska A, Wudarska B. Sensors (Basel). 2022;22:3536.

Interruptions and distractions in healthcare settings can inhibit safe care. This simulation study found that medical staff reaction time to changes in vital signs during stressful situations (telephone ringing, ambulance signal) was significantly slower than during non-stressful situations, which may increase the likelihood of medical errors.

Room of hazards: a comparison of differences in safety hazard recognition among various hospital-based healthcare professionals and trainees in a simulated patient room.

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Wang M, Banda B, Rodwin BA, et al. J Patient Saf. 2022;Epub May 16.

Prior studies have examined students’ ability to recognize safety hazards in patient rooms using simulation; however, most of these studies focus on a single type of healthcare provider (e.g., medical or nursing students). This study compared physicians, nurses, and other healthcare workers and found that nurses identified more hazards than other providers. All healthcare workers were challenged to identify hazards of omission and those requiring two-step thinking.

Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm.

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Wolf L, Gorman K, Clark J, et al. J Patient Saf. 2022;Epub May 25.

Human factors play an important role in contributing to and preventing adverse events. This study found that integrating human factors into a new root cause analysis process led to an increase in the number of strong interventions implemented after adverse events.

Safety-II and the study of healthcare safety routines: two paths forward for research.

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Rydenfält C. J Patient Saf Risk Manag. 2022;27:124-128.

Certain processes and routines, such as checklists, are widely used in healthcare settings to improve patient safety. In this article, the author describes two proposed approaches for the study of healthcare safety routines using human factors and a safety-II perspective.

Racial and ethnic discrepancy in pulse oximetry and delayed identification of treatment eligibility among patients with COVID-19.

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Fawzy A, Wu TD, Wang K, et al. JAMA Intern Med. 2022;182:730-738.

Black and brown patients have experienced disproportionately poorer outcomes from COVID-19 infection as compared with white patients. This study found that patients who identified as Asian, Black, or Hispanic may not have received timely diagnosis or treatment due to inaccurately measured pulse oximetry (SpO2). These inaccuracies and discrepancies should be considered in COVID outcome research as well as other respiratory illnesses that rely on SpO2 measurement for treatment.

Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes.

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Wooldridge AR, Carayon P, Hoonakker PLT, et al. Hum Factors. 2022;Epub Jun 5.

Handoffs between inpatient care settings represent a vulnerable time for patients. This qualitative study explores how team cognition occurs during care transitions and interprofessional handoffs between inpatient settings and the influence of sociotechnical systems, such as communication workflows or electronic heath record-based interfaces) influence team cognition. Participants highlighted how interprofessional handoffs can both enhance (e.g., information exchange) and hinder (e.g., logistic challenges and imprecise communication) team cognition.

Anesthesiologist group says hospitals can prevent fatal errors like Vanderbilt's.

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Clark C. MedPage Today. June 2, 2022

Transparency and discussion of errors is a hallmark of the culture needed to improve safety. This article summarizes an Anesthesia Patient Safety Foundation statement directing organizations and individuals that provide anesthesia care to protect patients and encourage learning from error. It provides context through a discussion of official reports and investigations of a high-profile incident that culminated in criminal charges for the clinician involved.

Adopt strategies to manage look-alike and/or sound-alike medication name mix-ups.

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ISMP Medication Safety Alert! Acute care edition. June 2, 2022;27(11):1-4.

Minimizing look-alike/sound-alike medication risk is a universal need across health care. This story highlights a primary prevention tool that lists problematic drug names. It shares strategies across the medication use process to reduce errors associated with similarly named and labeled medications such as separate storage areas and tall man lettering.

Human factors analysis of latent safety threats in a pediatric critical care unit.

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Trbovich PL, Tomasi JN, Kolodzey L, et al. Pediatr Crit Care Med. 2022;23:151-159.

Intensive care units (ICU) are high-risk environments. Based on direct observations, these researchers identified 226 latent safety threats affecting routine care activities in pediatric ICUs. Findings indicate that threats persist regardless of whether individuals comply with or deviate from policies and protocols, suggesting the need for targeted interventions beyond reinforcing compliance.

Check Twice, Transport Once

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May 16, 2022

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation.

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Salwei ME, Hoonakker PLT, Carayon P, et al. Hum Factors. 2022;Epub Apr 4.

Clinical decision support (CDS) systems are designed to improve diagnosis. Researchers surveyed emergency department physicians about their evaluation of human factors-based CDS systems to improve diagnosis of pulmonary embolism. Although perceived usability was high, use of the CDS tool in the real clinical environment was low; the authors identified several barriers to use, including lack of workflow integration.

At US hospitals, a drug mix-up is just a few keystrokes away.

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Kelman B. Kaiser Health News. April 29, 2022.

Technological solutions harbor unique risks that can result in patient harm. This article shares a response to reports of automated dispensing cabinet (ADC) menu selection limitations that contribute to mistakes. The piece suggests the implementation of a 5-letter search requirement prior to removing a medication from an ADC. It provides an update on industry response to this forcing function recommendation.

Habit and automaticity in medical alert override: cohort study.

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Wang L, Goh KH, Yeow A, et al. J Med Internet Res. 2022;24:e23355.

Alert fatigue is an increasingly recognized patient safety concern. This retrospective study examined the association between habit and dismissal of indwelling catheter alerts among physicians at one hospital in Singapore. Findings indicate that physicians dismissed 92% of all alerts and that 73% of alerts were dismissed in 3 seconds or less. The study also concluded that a physician’s prior dismissal of alerts increases the likelihood of dismissing future alerts (habitual dismissal), raising concerns that physicians may be missing important alerts.

Effect of the surgical safety checklist on provider and patient outcomes: a systematic review.

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Armstrong BA, Dutescu IA, Nemoy L, et al. BMJ Qual Saf. 2022;31:463-478.

Despite widespread use of surgical safety checklists (SSC), its success in improving patient outcomes remains inconsistent, potentially due to variations in implementation and completion methods. This systematic review sought to identify how many studies describe the ways in which the SSC was implemented and completed, and the impact on provider outcomes, patient outcomes, and moderating factors. A clearer positive relationship was seen for provider outcomes (e.g., communication) than for patient outcomes (e.g., mortality).

Using human factors and ergonomics principles to prevent inpatient falls.

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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.

eSIMPLER: a dynamic, electronic health record-integrated checklist for clinical decision support during PICU daily rounds.

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April 7, 2022

Checklists are used in many clinical settings to improve patient safety. This pediatric intensive care unit updated a static checklist, eSIMPLE, to a dynamic, decision-support enhanced checklist, eSIMPLER.

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