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Blandford A, Dykes PC, Franklin BD, et al. Drug Saf. 2019;42:1157-1165.
Intravenous medication infusions are an important target for safety interventions. Many infused medications, such as opioids and chemotherapy, require vigilant adherence to protocol to prevent harm. Technical solutions to infusion errors such as computerized provider order entry, barcode medication administration, and smart infusion pumps have been implemented with some success. Investigators compared infusion errors in the United States, where all three technical interventions are common, to the United Kingdom, where those technical interventions are rare. Minor errors were common in each country, but only 0.8% of infusions placed patients at serious risk of harm. Although the details of errors in both countries differed in detail, rates of error and harm were similar. A WebM&M commentary described a chemotherapy infusion error that caused renal failure.
Najafpour Z, Hasoumi M, Behzadi F, et al. BMC Health Serv Res. 2017;17:453.
Failure mode and effect analysis (FMEA) is a tool that facilitates prospective risk assessment and is frequently used to assess the risk of various processes in health care. The authors describe the use of FMEA at a single institution to improve the safety of the blood transfusion process.
Siam B, Al-Kurd A, Simanovsky N, et al. JAMA Surg. 2017;152:679-685.
Balancing supervision and autonomy for trainee physicians is a contested area in patient safety. This analysis of medical record data at a single institution compared complication rates following acute appendectomy between surgical resident physicians and attending surgeons. As measured by a composite score, the complication rate did not differ between trainees and attending surgeons. There was no difference in the rate of follow-up imaging, length of stay, or duration of antibiotics following surgery. On average, trainees took about 9 minutes longer to complete the surgery. The authors conclude that trainees do not require attending supervision to safely perform appendectomies. A related editorial calls for greater surgical resident autonomy and notes the importance of real-life experience with procedures to prepare residents for independent practice. A past PSNet perspective explored this tension between supervision and autonomy in medical education.
ALQahtani DA, Rotgans JI, Mamede S, et al. Acad Med. 2016;91:710-716.
Diagnosis is a critical area of patient safety. Prior research demonstrates that physicians perceive time pressure as an impediment to diagnosis, but this has not been objectively documented. This educational simulation study examined the ability of internal medicine residents to correctly diagnose written cases with and without time pressure. Residents under time pressure had reduced diagnostic accuracy, and this decrement was more marked for difficult cases. These results demonstrate the benefit of allowing physicians more time for accurate diagnosis, consistent with recent Institute of Medicine recommendations to examine novel models of care and reimbursement to foster diagnostic safety. A recent PSNet interview discussed diagnostic errors and how to reduce them.
Brezis M, Orkin-Bedolach Y, Fink D, et al. J Patient Saf. 2019;15:296-298.
Investigators presented medical students and physicians at three university medical centers with a clinical vignette to explore levels of confidence, accuracy, and comfort with admitting a mistake. Physicians had higher levels of confidence but less accuracy compared to medical students, and they were less willing to admit making an error. There was a weak association between overconfidence and discomfort with error disclosure.
Schnoor J, Rogalski C, Frontini R, et al. Patient Saf Surg. 2015;9:12.
Look-alike sound-alike medications can contribute to confusion and result in drug administration errors. This commentary illustrates how switching to a generic brand of medication to save costs was a factor in recurring underdosing errors. The authors provide recommendations to improve the safety of stocking medications.
Wilson RM, Michel P, Olsen S, et al. BMJ. 2012;344:e832.
This study conducted a retrospective chart review of more than 15,000 hospitalization records in 8 countries and found an adverse event rate range of 2.5% to 18.4% per country. Investigators estimated that more than 80% were preventable, suggesting a call to action for broader international efforts to promote patient safety.
Peberdy MA, Cretikos MA, Abella BS, et al. Circulation. 2007;116.
This consensus statement provides recommendations for collection of standardized data to optimize rapid response team efforts, in order to improve the outcomes of patients whose condition acutely deteriorates while they are hospitalized.