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This case involves a 2-year-old girl with acute myelogenous leukemia and thrombocytopenia (platelet count 26,000 per microliter) who underwent implantation of a central venous catheter with a subcutaneous port. The anesthetist asked the surgeon to order a platelet transfusion to increase the child’s platelet count to above 50,000 per microliter. In the post-anesthesia care unit, the patient’s arterial blood pressure started fluctuating and she developed cardiac arrest.

Chiel L, Freiman E, Yarahuan J, et al. Hosp Pediatr. 2021;12(1):e35-e38.
Medical residents write patient care orders overnight that are often not reviewed by attending physicians until the next morning. This study used the hospital’s data warehouse and retrospective chart review to examine 5927 orders over a 12-month period, 538 were included in the analysis. Key reasons for order changes included medical decision making, patient trajectory, and medication errors. Authors suggest errors of omission may be an area to direct safety initiatives in the future.
Kämmer JE, Schauber SK, Hautz SC, et al. Med Educ. 2021;55(10):1172-1182.
Checklists are increasingly used to improve diagnosis by supporting clinical decision making and ensuring that all possible diagnoses are considered. This study explored the effect of a prompt to generate alternative diagnoses versus a differential diagnosis checklist on diagnostic accuracy among medical students completing computer-generated patient cases. The researchers found that the checklist improved diagnostic accuracy compared to a prompt, but only if the checklist included the correct diagnosis; if the correct diagnosis was not included on the checklist, diagnostic accuracy was slightly reduced.  
Alsabri M, Boudi Z, Lauque D, et al. J Patient Saf. 2022;18(1):e351-e361.
Medical errors are a significant cause of morbidity and mortality, and frequently result from potentially preventable human errors associated with poor communication and teamwork. This systematic review included 16 studies that were examined for assessment tools, training interventions, safety culture improvement, and teamwork intervention outcomes. The authors conclude that training staff on teamwork and communication improve the safety culture, and may reduce medical errors and adverse events in the Emergency Department.
Etherington C, Kitto S, Burns JK, et al. BMC Health Serv Res. 2021;21(1):1357.
Gender bias has been implicated in negatively affecting patient safety. The authors conducted semi-structured interviews to explore how gender and other social identify factors impact experiences and teamwork in the operating room. Researchers found that women being routinely challenged or ignored or perceived negatively when assertive may hinder their pursuit of leadership positions or certain specialties. Implicit gender bias and stereotypes along with deeply entrenched structural barriers persist and complicate hierarchical relations between professions – all contributing to breakdowns in communication, increased patient safety risks, and poor team morale.  

Cohen M, Degnan D, McDonnell P, eds. Patient Saf. 2022;4(s1):1-45

Pharmacists play a unique role in patient safety that educational methods are shifting to address. This special issue covers several topics including strategies to reduce the susceptibility of hospitalized infants and children to medication errors, and infusing safety culture into pharmacy school curriculum.
Society to Improve Diagnosis in Medicine.
Diagnostic error is garnering increased attention as a key area of focus in patient safety improvement. This fellowship program for physicians who have completed their residency will provide the opportunity to build expertise in enhancing diagnostic safety. The application process for the 2022-2023 program closes on March 8. 2022.
Vaughan CP, Hwang U, Vandenberg AE, et al. BMJ Open Qual. 2021;10(4):e001369.
Prescribing potentially inappropriate medications (such as antihistamines, benzodiazepines, and muscle relaxants) can lead to adverse health outcomes. The Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIPPED) program is a multicomponent intervention intended to reduce potentially inappropriate prescribing among older adults who are discharged from the emergency department. Twelve months after implementation at three academic health systems, the EQUIPPED program significantly reduced overall potentially inappropriate prescribing at one site; the proportion of benzodiazepine prescriptions decreased across all sites.

Bryant A. UpToDate. September 13, 2021.

Implicit bias is progressively being discussed as a detractor to safe health care by fostering racial and ethnic inequities. This review examines the history of health inequities at the patient, provider, health care system, and cultural levels in obstetric and gynecologic care. It shares actions documented in the evidence base for application in health care to reduce the impact of implicit bias, with an eye toward maternal care
Brush JE, Sherbino J, Norman GR. BMJ. 2022;Epub Jan 7.
Misdiagnosis of heart failure can lead to serious patient harm. This article reviews the cognitive psychology of diagnostic reasoning in cardiology. Strategies for educators, students, and researchers to reduce cardiovascular misdiagnosis are presented.

The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety improvement strategies, and resources for design.

Al Rowily A, Jalal Z, Price MJ, et al. Eur J Clin Pharmacol. 2021;Epub Dec 22.
Although direct acting oral anticoagulants (DAOCs) are generally considered safer than older anticoagulants, they are still high-risk medications. This review found that between 5.3% and 37.3% of patients experienced either a prescription, administration, or dosing error. Prescribing errors constituted the majority of error types, and common causes were active failures, including wrong drug or wrong dose.
Holmes J, Chipman M, Barbour T, et al. Jt Comm J Qual Patient Saf. 2022;48(1):12-24.
Air medical transport carries unique patient safety risks. In this study, researchers used simulation training and healthcare failure mode and effect analysis (HFMEA) to identify latent safety threats related to patient transport via helicopter. This approach identified 31 latent safety threats (18 were deemed critical) related to care coordination, facilities, equipment, and devices.
Institute for Healthcare Improvement. April 6 - June 15, 2022.
Burnout among health care workers negatively affects system improvement. This webinar series will highlight strategies to establish a healthy work environment that strengthens teamwork, staff engagement, and resilience. Instructors include Dr. Donald Berwick and Derek Feeley.

Institute for Healthcare Improvement. March 15 - April 26, 2022.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.