Watson J, Salisbury C, Whiting PF, et al. Br J Gen Pract. 2022;Epub Jun 6.
Failure to communicate blood test results to patients may result in delayed diagnosis or treatment. In this study, UK primary care patients and general practitioners (GPs) were asked about their experiences with the communication of blood test results. Patients and GPs both expected the other to follow up on results and had conflicting experiences with the method of communication (e.g., phone call, text message).
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.
Järvinen TLN, Rickert J, Lee MJ. Clin Orthop Relat Res. 2013-2022.
This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.
Meyer AND, Scott TMT, Singh H. JAMA Netw Open. 2022;5:e228568.
Delayed communication of abnormal test results can contribute to diagnostic and treatment delays, patient harm, and malpractice claims. The Department of Veterans Affairs specifies abnormal test results be communicated to the patient within seven days if treatment is required, and within 14 days if no treatment is required. In the first full year of the program, 71% of abnormal test results and 80% of normal test results were communicated to the patient within the specified timeframes. Performance varied by facility and type of test.
Blijleven V, Hoxha F, Jaspers MWM. J Med Internet Res. 2022;24:e33046.
Electronic health record (EHR) workarounds arise when users bypass safety features to increase efficiency. This scoping review aimed to validate, refine, and enrich the Sociotechnical EHR Workaround Analysis (SEWA) framework. Multidisciplinary teams (e.g. leadership, providers, EHR developers) can now use the refined SEWA framework to identify, analyze and resolve unsafe workarounds, leading to improved quality and efficiency of care.
Root cause analysis is a commonly used tool to identify systems-related factors that contributed to an adverse event. This study assessed a system-based approach, (i.e., collaborative case reviews (CCR) co-led by radiology and an institutional patient safety program) to identify contributing factors and explore the strength of recommended actions in the radiology department at a large academic medical center. Stronger action items, such as standardization of processes, were implemented in 41% of events, and radiology had higher completion rates than other hospital departments.
Missed or incomplete nursing care can adversely affect care quality and safety. Based on survey responses from 295 frontline nurses in the Philippines, this study explored factors contributing to missed nursing care during the COVID-19 pandemic. Findings suggest that nurses most frequently missed tasks such as patient surveillance, comforting patients, skin care, ambulation, and oral hygiene. The authors suggest that increasing nurse staffing, adequate use of personal protective equipment, and improved safety culture may reduce instances of missed care.
Rajan SS, Baldwin JL, Giardina TD, et al. J Patient Saf. 2022;18:e262-e266.
Radiofrequency identification (RFID) technology has been most commonly used in perioperative settings to improve patient safety. This study explored whether RFID technology can improve process measures in laboratory settings, such as order tracking, specimen processing, and test result communication. Findings indicate that RFID-tracked orders were more likely to have completed testing process milestones and were completed more quickly.
Lyndon A, Simpson KR, Spetz J, et al. Appl Nurs Res. 2022;63:151516.
Missed nursing care appears to be associated with higher rates of adverse events. More than 3,600 registered nurses (RNs) were surveyed about missed care during labor and birth in the United States. Three aspects of nursing care were reported missing by respondents: thorough review of prenatal records, missed timely documentation of maternal-fetal assessments, and failure to monitor input and output.
Jomaa C, Dubois C‐A, Caron I, et al. J Adv Nurs. 2022;78:2015-2029.
Nurses play a critical role in ensuring patient safety. This study explored the association between the organization of nursing services and patient safety incidents in rehabilitation units. Findings highlight the key role of appropriate nurse staffing in reducing the incidence of events such as falls and medication errors
Blume KS, Dietermann K, Kirchner‐Heklau U, et al. Health Serv Res. 2021;56:885-907.
Nurse staffing levels have been shown to impact patient outcomes. Through an umbrella literature review and expert interviews, researchers developed a list of nurse-sensitive patient outcomes (NSPO). This list provides researchers potential avenues for future studies examining the link between nurse staffing levels and patient outcomes.
von Vogelsang A‐C, Göransson KE, Falk A‐C, et al. J Nurs Manag. 2021;29:2343-2352.
Incomplete nursing care can be detrimental to care quality and patient safety. This cross-sectional survey of nurses in Sweden at one acute care hospital did not identify significant differences in missed nursing care before and during the COVID-19 pandemic. The authors posit that these results may be attributed to maintaining nurse-patient ratios, sufficient nursing skill mix, and patient mix.
McHugh MD, Aiken LH, Sloane DM, et al. The Lancet. 2021;397:1905-1913.
While research shows that better nurse staffing ratios are associated with improved patient outcomes, policies setting minimum nurse-to-patient ratios in hospitals are rarely implemented. In 2016, select Queensland (Australia) hospitals implemented minimum nurse staffing ratios. Compared to hospitals that did not implement minimum nurse staffing ratios, length of stay, mortality, and readmission rates were significantly lower in intervention hospitals, providing evidence, once again, that minimum staffing ratios can improve patient outcomes.
Pryce A, Unwin M, Kinsman L, et al. Int Emerg Nurs. 2020;54:100956.
Emergency department (ED) overcrowding and prolonged ED stays can lead to adverse patient outcomes. This study examined patient flow bottlenecks in the ED and several factors posing risks to patient safety, such as prolonged time to triage and use of makeshift spaces (which may have inadequate staffing allocations or lack necessary equipment).
Peterson C, Moore M, Sarwani N, et al. Diagnosis (Berl). 2021;8:368-372.
Recent duty hour reforms are intended to improve patient safety and resident well-being. This study explored whether resident performance declines as a function of consecutive overnight shifts, but results indicate no significant trend in overnight report discrepancies between the night float resident and the daytime attending.
Salvador RO, Gnanlet A, McDermott C. Personnel Rev. 2020;50:971-984.
Prior research suggests that functional flexibility has benefits in several industries but may carry patient safety risks in healthcare settings. Using data from a national nursing database, this study examined the effect of unit-level nursing functional flexibility on the incidence of hospital-acquired pressure ulcers. Results indicate that higher use of functionally flexible nurses was associated with a higher number of pressure ulcers, but this effect was moderated when coworker support within the unit was high.
Lack of timely follow-up of test results is a recognized patient safety problem in primary care and can lead to missed or delayed diagnoses. This study used human factors methods to understand lack of timely follow-up of abnormal test results in outpatient settings. Through interviews with the ordering physicians, the researchers identified several contributing factors, such as provider-patient communication channel mismatch and diffusion of responsibility.
Lagoo J, Berry WR, Henrich N, et al. Jt Comm J Qual Patient Saf. 2020;46:314-320.
As part of a quality improvement initiative to enhance surgical onboarding, the authors used semi-structured interviews with 20 physicians to understand potential areas of risk when a physician begins working in an unfamiliar setting. Qualitative analysis found that three key findings: (1) physicians often receive little to no onboarding when starting to practice in a new setting, which can limit their ability to provide safe care; (2) physicians felt onboarding inadequately fostered strong interpersonal relationships among health care teams, which impedes psychological safety and team cohesion, and; (3) physicians noted an increased risk of patient harm during emergency situations in new settings due to lack of understanding of culture, workflow, roles/responsibilities and available equipment.
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