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1 - 14 of 14
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.

Chui MA, Pohjanoksa-Mäntylä M, Snyder ME, eds. Res Social Adm Pharm. 2019;15(7):811-906.

Medication safety is a worldwide challenge. This special issue discusses factors affecting the reliability of the ordering, dispensing, and administration of medications across a range of environments. Articles cover topics such as the need to deepen understanding of safety in community pharmacies, the use of smart pumps for high-alert medications, and the international effort to reduce medication-related harm.
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.
Catchpole K, Bisantz A, Hallbeck S, et al. Applied ergonomics. 2019;78:270-276.
Surgery requires specialized approaches to understand and prevent failure. This special issue features the work of multidisciplinary research teams that explored human factors and ergonomic concerns in the operating room that affect communication between robotic-assisted surgery teams, physical resilience of teams, instrument design and use, and poor implementation of briefings as improvement opportunities.
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.
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.
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.
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.
L'Hommedieu T, DeCoske M, Lababidi RE, et al. Am J Health Syst Pharm. 2015;72:1266-8.
Miscommunication during transitions of care can contribute to medication errors. This commentary describes an initiative to involve pharmacy students in care transitions services. Although the authors found that scheduling and training the students for the program was a challenge, 30-day readmission rates were lower for patients who received transitions of care services with pharmacy students versus those who did not.
Naveh E, Katz-Navon T, Stern Z. Adv Health Sci Educ Theory Pract. 2015;20:59-71.
This survey study examined the relationship between medical errors and resident autonomy, consultation with supervising physicians, and knowledge of the medical literature (as perceived by supervising physicians). Researchers found that closer supervision and greater knowledge were associated with lower error rates, suggesting that increasing trainee supervision holds promise in improving patient safety.