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van Heesch G, Frenkel J, Kollen W, et al. Jt Comm J Qual Patient Saf. 2020;47:234-241.
Poor handoff communication can threaten patient safety. In this study set in the Netherlands, pediatric residents were asked to develop a contingency plan for patients received during handoffs and asked to recall information from that handoff five hours later. Results indicate that engaging in deliberate cognitive processing during handoffs resulted in better understanding of patients’ problems, which could contribute to improved patient safety.
Hendy J, Tucker DA. J Bus Ethics. 2020;2021;172:691–706.
Using the events at the United Kingdom’s Mid Staffordshire Trust hospital as a case study, the authors discuss the impact of ‘collective denial’ on organizational processes and safety culture. The authors suggest that safeguards allowing for self-reflection and correction be implemented early in the safety reporting process, and that employees be granted power to speak up about safety concerns.
Trivedi A, Sharma S, Ajitsaria R, et al. Arch Dis Child Educ Pract Ed. 2019;105:122-126.
Medication reconciliation to ensure accuracy of patient medication lists has been difficult to implement. This project report describes an initiative to enhance the timeliness of medication reconciliation for pediatric inpatients. Use of Plan-Do-Study-Act cycles helped inform the evolution of the work. The authors emphasize the importance of engaging the entire care team as well as patients and families to enable completion of the process.
National Pharmacy Association; NPA.
This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
Cheong V-L, Tomlinson J, Khan S, Petty D. Prescriber. 2019;30:29-34.
Geriatric patients are particularly vulnerable to medication-related harm. This article summarizes types of incidents and contributing factors to adverse drug events in older patients after hospital discharge. The authors recommend strategies to reduce medication-related harm, including discharge communication improvements, primary care collaboration, and postdischarge patient education.
Griffiths P, Maruotti A, Saucedo AR, et al.  BMJ Qual Saf. 2019;28:609-617.
There is a clear link between nurse staffing ratios and patient safety. This study corroborates the finding that lower registered nurse staffing and higher numbers of patients admitted per nurse are associated with increased rates of in-hospital mortality. The results underscore the importance of adequate nursing to ensure safe acute care.
Griffiths P, Ball JE, Bloor K, et al. National Institute for Health Research; 2018.
Missed nursing care has been linked to safety problems, but ensuring reliable levels of nurse staffing remains challenging. This report provides the results of a 3-year investigation into whether tracking of vital signs by nursing staff could serve as a viable measure for safe patient coverage. The report identified correlations between low staffing, missed vital sign observation, length of stay, and likelihood of mortality. However, record review found no direct relationship between safety and staffing levels. A PSNet perspective examined the relationship between missed nursing care and patient safety.
Müller M, Jürgens J, Redaèlli M, et al. BMJ Open. 2018;8:e022202.
Standardized handoff tools are increasingly implemented to improve communication between health care providers. Although this systematic review identified several studies supporting the use of SBAR as a communication tool to improve patient safety, the authors suggest the evidence is moderate and that further research is needed.
Redmond P, Grimes TC, McDonnell R, et al. Cochrane Database Syst Rev. 2018;8:CD010791.
This systematic review identified 25 randomized controlled trials of methods to improve medication reconciliation at the time of hospital discharge, most of which involved a pharmacist-mediated intervention. Overall, there was no clear evidence that medication reconciliation interventions reduced either medication discrepancies or adverse drug events. A previous commentary discussed the challenges in implementing effective medication reconciliation programs in real-world settings.
Griffiths P, Recio-Saucedo A, Dall'Ora C, et al. J Adv Nurs. 2018;74:1474-1487.
Inadequate hospital nurse staffing is linked to increased mortality. This systematic review found that lower nurse staffing is associated with more reports of missed nursing care. Two of the authors summarized the science of missed nursing care in a recent PSNet perspective.
Gilliland N, Catherwood N, Chen S, et al. BMJ Open Qual. 2018;7:e000170.
Incomplete communication regarding patient information can diminish the safety of care delivery. This commentary describes how a quality improvement project applied plan–do–study–act cycles to enhance collection of patient data. Researchers developed, tested, and refined a ward round template in a United Kingdom urology service and increased compliance in the recording of patient care measures.
London, UK: Parliamentary and Health Service Ombudsman; 2017. ISBN: 9781528601344.
Patients with mental health conditions face particular safety challenges. This report describes incidents involving patients with eating disorders who experienced harm while receiving care in National Health Service organizations. Factors that contributed to the failures included poor care coordination, premature discharge, and lack of monitoring. The report discusses gaps in the investigations of these patient deaths and outlines areas of improvement.
Sasso L, Bagnasco A, Aleo G, et al. BMJ Qual Saf. 2017;26:929-932.
Multiple factors in the hospital environment influence the incidence of missed nursing care. This commentary describes strategies to address these errors of omission, including changing mental models to recognize the financial benefit of increasing staffing levels to improve patient safety.
Ball JE, Bruyneel L, Aiken LH, et al. Int J Nurs Stud. 2018;78:10-15.
Missed nursing care may result from inadequate nurse staffing and explain the relationship between nurse-to-patient ratios and patient outcomes. Research has shown that higher nurse staffing levels are associated with lower inpatient mortality and that reduced staffing increases the risk for postoperative complications. In this study, investigators examined data from more than 400,000 surgical patients from 300 hospitals in 9 countries as well as survey responses from 26,516 nurses. They found a significant association between nurse staffing and missed nursing care with 30-day risk-adjusted postoperative mortality. The authors conclude that measuring missed nursing care may help identify patients at greater risk for adverse outcomes earlier in their course. A past WebM&M commentary highlighted important issues associated with nurse staffing ratios.
Wibrandt I, Lippert A. J Patient Saf. 2020;16:199-210.
This systematic review of handoffs from intensive care to general ward identified eight intervention studies, none of which demonstrated improved mortality or lower readmission rates. Handoff strategies differed widely among the included studies. The authors recommend further study to identify best handoff practices for patients discharged from intensive care.
Alabdali A, Fisher JD, Trivedy C, et al. Air Med J. 2017;36:116-121.
Interfacility transport of critically ill patients may be performed by physician-led teams or by paramedics without direct physician involvement. This systematic review attempted to determine if transport by paramedics alone was safe for patients, but researchers found only a small number of studies with limited characterization of the types of adverse events encountered in this situation.
Puvaneswaralingam S, Ross D. BMJ Qual Improv Rep. 2016;5.
Boarding patients as they transfer between wards can compromise patient safety. This commentary reviews how an otolaryngology ward implemented a simple cognitive aid to improve patient record review, information sharing, and team communication. The authors report the results of the project and how they intend to use plan-do-study-act cycles to refine the process.