Webster KLW, Keebler JR, Lazzara EH, et al. Jt Comm Qual Patient Saf. 2022;48:343-353.
Effective handoff communication is a key indicator of safe patient care. These authors outline a new model for handoff communication, integrating three theoretical frameworks addressing relevant inputs (i.e., individual organizational, environmental factors), mediators (e.g., communication, leadership), outcomes (e.g., patient, provider, teamwork, and organizational outcomes), and adaptation loops.
Lazzara EH, Simonson RJ, Gisick LM, et al. Ergonomics. 2022;65:1138-1153.
Structured handoffs support appropriate communication between teams or departments when transferring responsibility for care. This meta-analysis aimed to determine if structured, standardized post-operative anesthesia handoffs improved provider, patient, organizational and handoff outcomes. Postoperative outcomes moved in a generally positive direction when compared with non-standardized handoffs. The authors suggest additional research into pre- and intra-operative handoffs is needed.
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.
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).
Sun LY, Jones PM, Wijeysundera DN, et al. JAMA Netw Open. 2022;5:e2148161.
Previous research identified a relationship between anesthesia handoffs and rates of major complications and mortality compared to patients who had the same anesthesiologist throughout their procedure. This retrospective cohort study including over 102,000 patients in Ontario, Canada, explored this relationship among patients undergoing cardiac surgery. Analyses revealed that anesthesia handovers were associated with poorer outcomes (i.e., higher 30-day and one-year mortality rates, longer hospitalizations and intensive care unit stays) compared with patients who had the same anesthesiologist throughout their procedure.
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.
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.
Abraham J, Pfeifer E, Doering M, et al. Anesth Analg. 2021;132:1563-1575.
Intraoperative handoffs between anesthesiologists are frequently necessary but are not without risk. This systematic review of 14 studies of intraoperative handoffs and handoff tools found that use of handoff tools has a positive impact on patient safety. Additional research is needed around design and implementation of tools, particularly the use of electronic health records to record handoffs.
Abraham J, Meng A, Tripathy S, et al. BMJ Qual Saf. 2021;30:513-524.
Handoffs are essential to communicating important information and preventing adverse outcomes. This systematic review found that bundled interventions commonly used to support handoffs between the operating room and intensive care units included information transfer/communication checklists and protocols. A meta-analysis showed that bundled interventions resulted in significant improvements for a number of clinical and process outcomes, such as time to analgesia dosing, fewer information omissions, and fewer technical errors.
Mangrum R, Stewart MD, Gifford DR, et al. J Am Med Dir Assoc. 2020;21:1587-1591.e2.
Building upon earlier work, the authors engaged a technical expert panel to reach consensus on a definition for omissions of care in nursing homes. The article details the terms and concepts included in (and excluded from) the proposed definition, provides examples of omissions of care, intended uses (e.g., to guide quality improvement activities or training and education), and describes the implications of the definition for clinical practice, policy, and research.
Boet S, Djokhdem H, Leir SA, et al. Br J Anaesth. 2020;125:605-613.
Handoffs between providers can introduce patient safety risks. This systematic review explored the impacts of intraoperative anesthesia handovers (e.g., intraoperative relief, transferring care to an incoming provider) on patient safety outcomes. The researchers pooled four studies and found that an intraoperative anesthesia handover significantly increases the risk of an adverse event by 40%.
Lau VI, Priestap FA, Lam JNH, et al. J Intensive Care Med. 2020;35:1067-1073.
Many factors can contribute to early, unplanned readmissions among critical care patients. In this prospective cohort study, adult patients who were discharged directly home after an ICU admission were followed for 8 weeks post-discharge to explore the predictors of adverse events and unplanned return visits to a health care facility. Among 129 patients, there were 39 unplanned return visits. Researchers identified eight predictors of unplanned return visits including prior substance abuse, hepatitis, discharge diagnosis of sepsis, ICU length of stay exceeding 2 days, nursing workload, and leaving against medical advice.
Handoffs are essential to communicating important information and preventing adverse patient care outcomes. This qualitative study explored how information about ICU patients’ family members is included in handovers. Findings suggest that written documentation about the family is inadequate and poorly structured and there is a need for user-friendly handoff tools that include information on patients’ family members.
Ashcroft J, Wilkinson A, Khan M. J Surg Educ. 2020;78:245-264.
This systematic review explored the different approaches taken by the United States and the United Kingdom to implement crew resource management (CRM) training. CRM in the United Kingdom had an emphasis on physicians and focused on skills outcomes using pre- and post-training questionnaires, whereas CRM in the United States focused on behavior outcomes and nontechnical skills utilizing multidisciplinary teams.
Alqenae FA, Steinke DT, Keers RN. Drug Saf. 2020;43:517-537.
This systematic review of 54 studies found that over half of adult and pediatric patients experienced a medication error post-discharge, and that these errors regularly involved common drug classes such as antibiotics, antidiabetics, analgesics, and cardiovascular drugs. The authors suggest that future research examine the burden of post-discharge medication errors, particularly in pediatric populations.
Vyas DA, Eisenstein LG, Jones DS. N Engl J Med. 2020;383(9):874-882.
Physicians commonly use diagnostic algorithms and practice guidelines to individualize risk assessment and guide clinical decisions. The authors discuss the possible dangers of using race-adjusted algorithms due to their potential to lead to diagnostic errors and delays in care.
Ogletree AM, Mangrum R, Harris Y, et al. J Am Med Dir Assoc. 2020;21:604-614.e6.
To support the development of a uniform definition of omissions of care in nursing home settings, the authors conducted a thematic analysis of 34 articles describing existing definitions and found broad agreement that delays or failure of care constitutes an omission of care, but differing views on whether to include adverse events in the definition of omissions of care. The authors reviewed an additional 327 articles reporting adverse events attributable to omissions of care, and identified nineteen event types, with the most common being all-cause mortality, falls, and infections.
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.
Herledan C, Baudouin A, Larbre V, et al. Support Care Cancer. 2020;28:3557-3569.
This systematic review synthesizes the evidence from 14 studies on medication reconciliation in cancer patients. While the majority of studies did not include a contemporaneous comparison group, they did report that medication reconciliation led to medication error identification (most frequently drug omissions, additions or dosage errors) in up to 88-95% of patients.
Prior research has found poor communication between hospital-based and primary care physicians and has suggested that this may contribute to medical errors. This systematic review included 19 studies assessing the transfer of information at hospital discharge between hospital-based and primary care providers (PCPs), or evaluating interventions aimed at improving the timeliness and quality of discharge information. The review found that timely communication of discharge summaries was low, with 55% (median) transferred to PCPs within 48 hours and 85% (median) within 4-weeks; 8.5% of discharge summaries were never transferred. Discharge summaries nearly always contained patient demographics, admission/discharge dates and primary diagnoses, but less frequently included pending test results, diagnostic tests performed and discharge medications.
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