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English M, Ogola M, Aluvaala J, et al. Arch Dis Child. 2021;106:326-332.
Health systems are encouraged to proactively identify patient safety risks. In the first of a two-part series, the authors draw on the  Systems Engineering Initiative for Patient Safety (SEIPS) framework  to discuss the strengths and challenge of a low-resource newborn unit from a systems perspective and SEIPS’ implications for patient safety.
Vincent CA, Mboga M, Gathara D, et al. Arch Dis Child. 2021;106:333-337.
In the second of a two-part series, using examples from newborn units, the authors present a framework for supporting practitioners in low-resource settings to improve patient safety across four areas: (1) prioritizing critical processes, (2) improving the organization of care, (3) control of risks, and (4) enhancing responses to hazardous situations.
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.
Tetteh EK. Res Social Adm Pharm. 2019;15:827-840.
This commentary introduces the World Health Organization effort to improve medication safety: Medication Without Harm. The author focuses on how strategies and tools, including an intervention framework and guidelines to support safe medication use, can be used in low-resource countries to reduce avoidable harm by 50% in 5 years.
Mianda S, Voce A. BMC Health Serv Res. 2018;18:747.
Clinical leadership training and teamwork training both augment the safety of maternity care. This systematic review found that most leadership training in maternity settings used a work-based learning approach rather than simulation or classroom interventions. The authors emphasize the importance of tailoring leadership interventions to low- and middle-income countries, where this training is less common.
Hamiel U, Hecht I, Nemet A, et al. Postgrad Med J. 2018;94:254-258.
Abbreviations are both ubiquitous in clinical documentation and frequently misinterpreted. This cross-sectional Israeli study found that only 1.2% of physicians could understand 50% or more of the abbreviations in ophthalmologists' notes. Israeli physicians document in Hebrew, but ophthalmologists there favor English abbreviations. The authors suggest that use of abbreviations should be discouraged due to the potential for misinterpretations to affect patient care.
Simsekler MCE, Ward JR, Clarkson J. Ergonomics. 2018;61:1046-1064.
In aviation and other high reliability industries, organizations prioritize proactive risk identification in addition to root cause analysis after safety events occur. Researchers developed a risk identification framework for their health system and tested its feasibility with health care workforce members.
Mekonnen AB, McLachlan AJ, Brien J-AE, et al. J Pharm Policy Pract. 2018;11:2.
Researchers conducted eight focus groups to understand how to better engage Ethiopian hospital pharmacists in medication safety. Most expressed enthusiasm about having an active role in safety as long as concerns related to space, resources, and training were addressed. A recent PSNet perspective examined team-based approaches to improving safety during hospital discharge.
Bejnordi BE, Veta M, van Diest PJ, et al. JAMA. 2017;318:2199-2210.
Diagnostic error is a growing area of focus within patient safety. Artificial intelligence has the potential to improve the diagnostic process, both in terms of accuracy and efficiency. In this study, investigators compared the use of automated deep learning algorithms for detecting metastatic disease in stained tissue sections of lymph nodes of women with breast cancer to pathologists' diagnoses. The algorithms were developed by researchers as part of a competition and their performance was assessed on a test set of 129 slides, 49 with metastatic disease and 80 without. A panel of 11 pathologists evaluated the same slides with a 2-hour time limit and one pathologist evaluated the slides without any time constraints. The authors conclude that some of the algorithms demonstrated better diagnostic performance than the pathologists did, but they suggest that further testing in a clinical setting is warranted. An accompanying editorial discusses the potential of artificial intelligence in health care.
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.
Sholomovich L, Magnezi R. Am J Infect Control. 2017;45:677-681.
Health care–associated infections (HAIs) are a significant source of preventable harm to patients. Although prior research has shown that clean hands are essential for reducing HAIs, health care institutions continue to struggle with hand hygiene compliance. In this study, investigators surveyed 400 nurses at a pediatric hospital and found a positive correlation between psychological safety and belief in personal responsibility for preventing the spread of infection. The authors argue that improving the psychological safety of staff may augment the response to hand hygiene initiatives.
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.
Zohar D, Werber YT, Marom R, et al. BMJ Qual Saf. 2017;26:653-662.
This randomized controlled trial randomized head nurses in inpatient settings to either receive individual feedback based on questionnaires from frontline nurses followed by goal-setting, versus a summary report of feedback at the end of the intervention. In the intervention group, patient care messages increased and blaming decreased, demonstrating that a brief and feasible intervention can enhance safety culture.
Alolayan A, Alkaiyat M, Ali Y, et al. BMJ Qual Improv Rep. 2017;6.
Complex care regimens and poor team communication can influence the safety of patients with cancer. This project report describes how an organization used a standardized communication tool to augment physician handovers of oncology patients. The authors utilized plan-do-study-act cycles to refine the process. They found that each adjustment addressed challenges to the use of the tool and over time physician compliance with the process increased.
Minha S'ar, Shefet D, Sagi D, et al. PLoS One. 2016;11:e0150122.
This study surveyed trainees following a pre-internship simulation patient safety workshop. Most participants considered the workshop valuable for professional training and thought that it should be mandated. These results add to the evidence supporting simulation for patient safety education.
Bashkin O, Caspi S, Swissa A, et al. J Patient Saf. 2020;16:47-51.
This pre-post study found that a human factors approach improved blood collection procedures in the emergency department, which is important for preventing adverse events such as transfusion errors. This demonstrates the benefits of applying human factors engineering in patient safety efforts across health care settings.
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.