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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.

Missed nursing care in the critical care unit, before and during the COVID-19 pandemic: a comparative cross-sectional study.

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Falk A-C, Nymark C, Göransson KE, et al. Intensive Crit Care Nurs. 2022:103276.

Needed nursing care that is delayed, partially completed, or not completed at all is known as missed nursing care (MNC). Researchers surveyed critical care registered nurses during two phases of the COVID-19 pandemic about recent missed nursing care, perceived quality of care, and contributing factors. There were no major changes in the types of, or reasons for, MNC compared to the reference survey completed in fall 2019.

AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI: Final Report.

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Molefe A, Hung L, Hayes K, et al. Rockville MD: Agency for healthcare Research and Quality; 2022. AHRQ Publication No. 17(22)-0019.

Central line associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) are a persistent challenge for health care safety. This report shares the results of a 6-cohort initiative to reduce CLABSI and/or CAUTI infection rates in adult critical care. Recommendations for collaborative implementation success are included.

Communication patterns during routine patient care in a pediatric intensive care unit: the behavioral impact of in situ simulation.

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Ulmer FF, Lutz AM, Müller F, et al. J Patient Saf. 2022;18:e573-e579.

Closed-loop communication is essential to effective teamwork, particularly during complex or high-intensity clinical scenarios. This study found that participation in a one-day simulation team training for pediatric intensive care unit (PICU) nurses led to significant improvements in closed-loop communication in real-life clinical situations.

Longitudinal evaluation of a pediatric rapid response system with realist evaluation framework.

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Acorda DE, Bracken J, Abela K, et al. Jt Comm J Qual Patient Saf. 2022;48:196-204.

Rapid response (RR) systems are used to improve clinical outcomes and prevent transfer to ICU of patients demonstrating signs of rapid deterioration. To evaluate its RR system, one hospital’s pediatric department reviewed all REACT (Rapid Escalation After Critical Transfer) events (i.e., cardiopulmonary arrest and/or ventilation and/or hemodynamic support) which occurred within 24 hours of the RR. These reviews identified opportunities for systemwide improvements.

Toolkit for Preventing CLABSI and CAUTI in ICUs.

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Rockville, MD: Agency for Healthcare Research and Quality; April 2022.

Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this customizable, educational toolkit uses the Comprehensive Unit-based Safety Program (CUSP) and other evidence-based practices to provide clinical and cultural guidance to support practice changes to prevent and reduce central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) rates in intensive care units (ICUs). Sections of the kit include items such an action plan template, implementation playbook, and team interaction aids.

Effects of tall man lettering on the visual behaviour of critical care nurses while identifying syringe drug labels: a randomised in situ simulation.

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Lohmeyer Q, Schiess C, Wendel Garcia PD, et al. BMJ Qual Saf. 2022;Epub Mar 8.

Tall Man lettering (TML) is a recommended strategy to reduce look-alike or sound-alike medication errors. This simulation study used eye tracking to investigate how of ‘tall man lettering’ impacts medication administration tasks. The researchers found that TML of prelabeled syringes led to a significant decrease in misidentified syringes and improved visual attention.

We are not there yet: a qualitative system probing study of a hospital rapid response system.

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Olsen SL, Søreide E, Hansen BS. J Patient Saf. 2022;Epub Apr 4.

Rapid response systems (RRS) are widely used to identify signs of rapid deterioration among hospitalized patients. Using in situ simulation, researchers identified obstacles to effective RRS execution, including inconsistent education and documentation, lack of interpersonal trust, and low psychological safety.

Family support role in hospital rapid response teams: a scoping review.

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Howlett O, Gleeson R, Jackson L, et al. JBI Evid Synth. 2022;Epub Mar 4.

Rapid response teams are designed to provide emergency medical support to deteriorating hospitalized patients. This review examines the role of a family support person (FSP) as part of the rapid response team. The FSP supported the family during the resuscitation in numerous ways, such as explaining jargon and medical procedures and attending to the practical needs of the family.

The University of Michigan Emergency Critical Care Center (EC3) Provides Timely Intensive Care to Critically Ill Patients in the Emergency Department

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April 7, 2022

An increasing volume of patients presenting for acute care can create a need for more ICU beds and intensivists and lead to longer wait times and boarding of critically ill patients in the emergency department (ED).¹ Data suggest that boarding of critically ill patients for more than 6 hours in the emergency department leads to poorer outcomes and increased mortality.^2,3 To address this issue, University of Michigan Health, part of Michigan Medicine, developed an ED-based ICU, the first of its kind, in its 1,000-bed adult hospital.

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.

Increased mortality and costs associated with adverse events in intensive care unit patients.

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Cantor N, Durr KM, McNeill K, et al. J Intensive Care Med. 2022;Epub Mar 3.

Adverse events (AE) may lead to poor patient outcomes as well as increased financial costs. An analysis of more than 17,000 adult intensive care unit patients showed approximately 35% experienced at least one healthcare associated adverse event. Those patients had significantly longer hospital stays, experienced higher rates of in-hospital mortality, and required more invasive intensive care unit (ICU) interventions. Additionally, the total cost of the hospital stay was significantly higher, mostly due to increased length of stay.

Periodic resuscitation cart checks and nurse situational awareness: an observational study.

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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.

Patient harm and institutional avoidability of out-of-hours discharge from intensive care: an analysis using mixed methods.

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Vollam S, Gustafson O, Morgan L, et al. Crit Care Med. 2022;Epub Mar 7.

This mixed-method study explored the reasons why out-of-hours discharges from the ICU to the ward, and nighttime coverage are associated with poor outcomes. Based on qualitative interviews with patients, family members, and staff involved in the ICU discharge process, this study found that out-of-hours discharges are considered unsafe due to nighttime staffing levels and skill mix. Out-of-hours discharges often occurred prematurely, without adequate handovers, and involved patients who were not physiologically stable, and at risk for clinical deterioration.

Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.

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Shafer GJ, Singh H, Thomas EJ, et al. J Perinatol. 2022;Epub Mar 4.

Patients in the neonatal intensive care unit (NICU) are at risk for serious patient safety threats. In this retrospective review of 600 consecutive inborn NICU admissions, researchers found that the frequency of diagnostic errors among inborn NICU patients during the first seven days of admission was 6.2%.

Remote patient monitoring during COVID-19: an unexpected patient safety benefit.

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Pronovost PJ, Cole MD, Hughes RM. JAMA. 2022;327:1125-1126.

The COVID pandemic has increased demand and acceptance of remote care modalities. This commentary suggests that home monitoring is a promising telehealth approach and that its application could improve value while enhancing safety for hospital-at-home and other levels of home-based care patients.

Bedside clinicians' perceptions on the contributing role of diagnostic errors in acutely ill patient presentation: a survey of academic and community practice.

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Huang C, Barwise A, Soleimani J, et al. J Patient Saf. 2022;18:e454-e462.

Identifying and reducing diagnostic errors remains a critical patient safety concern. This prospective study asked clinicians if they perceived that a diagnostic error played a part in rapid response team activations or unplanned admissions to the intensive care unit. Clinicians reported that 18% of acute care patients experienced diagnostic errors.

Use of pediatric injectable medicines guidelines and associated medication administration errors: a human reliability analysis.

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Jones MD, Clarke J, Feather C, et al. Ann Pharmacother. 2021;55:1333-1340.

Medication errors during pediatric resuscitation are common. Using video recordings of simulated pediatric resuscitations, the researchers explored deviations in care related to the delivery of intravenous medicine. Findings suggest that deviations play a crucial role in intravenous medication administration errors, and deviations were more likely to occur during the use of an online injectable medicine guideline.

Exploring changes in patient safety incidents during the COVID-19 pandemic in a Canadian regional hospital system: a retrospective time series analysis.

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Lombardi J, Strobel S, Pullar V, et al. J Patient Saf. 2022;Epub Feb 10.

The COVID-19 pandemic dramatically changed healthcare delivery and has raised new patient safety concerns. This retrospective study investigated the impact of the first wave of COVID-19 on patient safety incidents at one health system in Ontario, Canada. Researchers identified significant changes in the composition of events – such as increase in falls – which may reflect changes in care processes (e.g., reduced patient surveillance, use of personal protective equipment) occurring during that time.

Care transition of trauma patients: processes with articulation work before and after handoff.

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Wooldridge AR, Carayon P, Hoonakker PLT, et al. Appl Ergon. 2022;98:103606.

Care transitions can increase the risk of patient safety events. Using the Systems Engineering Initiative for Patient Safety (SEIPS) model, this study explored care transitions between operating rooms and inpatient critical care units and the importance of articulation work (i.e., preparation and follow-up activities related to transitions) to ensure safe transitions.

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