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Willis E, Brady C. Nurs Open. 2022;9:862-871.
Incomplete nursing care can negatively affect care quality and safety. This rapid review found that missed or omitted nursing care in adults contributes to increased mortality, adverse events, and clinical deterioration. Included studies cited several causes (e.g., environmental factors, staffing levels and skill mix) as well as solutions (e.g., education, process redesign).
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.

Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 5, 2021. Report No. 20-01521-48.

 

This investigation examined care coordination, screening and other factors that contributed to a patient death by suicide shortly after discharge from a Veteran’s Hospital. Event reporting, disclosure and evaluation gaps were identified as process weaknesses to be addressed. 
Arshad SA, Ferguson DM, Garcia EI, et al. J Surg Res. 2021;257:455-461.
Engaging patients and families is an important strategy in ensuring safe health care delivery. In this prospective, observational study, use of a parent-centered script did not improve parent engagement during the preinduction checklist and resulted in an expected decline in checklist adherence.  
Bhat A, Mahajan V, Wolfe N. J Clin Neurosci. 2021;85:27-35.
Misdiagnosis, variation in treatment of stroke and gaps in secondary prevention in young patients can result in adverse outcomes. This article discusses the possible causes of implicit bias in stroke care in this population, the effects of bias on patient outcomes, and interventions to circumvent implicit bias.  
Lam BD, Bourgeois FC, Dong ZJ, et al. J Am Med Inform Assoc. 2021;28:685-694.
Providing patients access to their medical records can improve patient engagement and error identification. A survey of patients and families found that about half of adult patients and pediatric families who perceived a serious mistake in their ambulatory care notes reported it, but identified several barriers to reporting (e.g. no clear reporting mechanism, lack of perceived support).  

Office of the Inspector General. Washington, DC: Department of Veterans Affairs; July 28, 2020. Report Number 19-07507-214.

Patient suicide is a never event. This report analyzes the death of a veteran after presenting at an emergency room with suicidal ideation. The analysis found lack of both suicide prevention policy adherence and appropriate assessment, as well as a lack concern for the patient’s condition contributed to the failure.   
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.
Abdelhadi N, Drach‐Zahavy A, Srulovici E. J Adv Nurs. 2020;76:2161-2170.
This qualitative study conducted focus groups with 28 registered nurses working in different hospital settings to explore perspectives regarding decision-making and personal or contextual attributes leading to missed nursing care.  Three themes emerged based on the analysis: missed nursing care can result due to scarce resources or nurses’ agency, differences in thinking based on routine or novel situations, and situational factors triggering fluctuations in their awareness (such as difficult patients or the presence of family). The authors suggest that organizational training programs should encourage nurses to identify barriers and facilitators of missed nursing care and approaches to overcome these factors.
A 52-year old women presented to the emergency department with a necrotizing soft tissue infection (necrotizing fasciitis) after undergoing cosmetic abdominoplasty (‘tummy tuck’) elsewhere. A lack of communication and disputes between the Emergency Medicine, Emergency General Surgery and Plastic Surgery teams about what service was responsible for the patient’s care led to delays in treatment. These delays allowed the infection to progress, ultimately requiring excision of a large area of skin and soft tissue.
A 63-year-old woman with hematemesis was admitted by a 2nd year medical resident for an endoscopy. The resident did not spend adequate time discussing her code status and subsequently, made a series of errors that failed to honor the patient’s preferences and could have resulted in an adverse outcome for this relatively healthy woman.
A 62-year-old man with a history of malnutrition-related encephalopathy was admitted for possible aspiration pneumonia complicated by empyema and coagulopathy. During the hospitalization, he was uncooperative and exhibited signs of delirium. For a variety of reasons, he spent two weeks in the hospital with minimal oral intake and without receiving most of his oral medications, putting him at risk for complications and adverse outcomes.
Denson JL, Knoeckel J, Kjerengtroen S, et al. BMJ Qual Saf. 2019;29:250-259.
Handoffs are a vulnerable time for patients in which inadequate communication between providers can contribute to adverse outcomes; end-of-rotation handoffs have been found to put patients at even greater risk. Standardizing handoffs has been shown to improve patient safety. This single-center pilot study examined the impact of an ICU handoff intervention consisting of an in-person bedside handoff, a checklist, nursing involvement, and an education session. The authors found that the intervention was feasible to implement with high fidelity and did not improve length of stay or mortality.
O'Reilly-Shah VN, Melanson VG, Sullivan CL, et al. BMC Anesthesiol. 2019;19:182.
Utilizing American College of Surgeons National Surgical Quality Improvement Project  (ACS NSQIP) data, the authors looked at the effects of intraoperative handoffs  involving anesthesia personnel in two hospitals. Initial findings of higher rates of adverse outcomes were no longer statistically significant when confounding variables were added to the analysis.
Bloodworth LS, Malinowski SS, Lirette ST, et al. Journal of the American Pharmacists Association: JAPhA. 2019;59:896-904.
Medication reconciliation is one potential strategy for preventing adverse events and readmissions. This study examined a pharmacist-led intervention involving collaborations with inpatient and community-based pharmacists to provide pre-discharge and 30-day medication reconciliation. There were indications that this type of intervention can reduce readmission rates, but further investigation in larger populations is necessary.  
Meisenberg B, Zaidi S, Franks L, et al. J Hosp Med. 2019;14:716-718.
Advanced Directives (AD) and Physician Orders for Life-Sustaining Therapy (POLST) are intended to improve end-of-life care by ensuring that patient's wishes are honored by health care providers. This perspective presents two cases in which preventable errors allowed for the use of unwanted life-sustaining therapies. Root cause analyses for these cases found that haste, inadequate communication, EMR discrepancies, knowledge deficits contributed to these errors.