Marsh KM, Turrentine FE, Knight K, et al. Ann Surg. 2022;275:1067-1073.
Having standardized definitions and classifications of errors allows researchers to better understand potential causes and interventions for improvement. This systematic review identified six broad error categories, 13 definitions of error, and 14 study methods in the surgical error literature. Development and use of a common definition and taxonomy of errors will provide a more accurate indication of the prevalence of surgical error rates.
Clinician well-being has important implications for patient safety and quality of healthcare delivery. In this study, researchers used a concept analysis to identify attributes of nurse well-being at the individual level (e.g., satisfaction, compassion) and organizational/community level (e.g., teamwork, pride in work). These findings can support the development of a standardized definition of nurse well-being to guide future research and policy considerations around well-being and burnout.
Bail K, Gibson D, Acharya P, et al. Int J Med Inform. 2022;165:104824.
A range of health information technologies (e.g., computerized provider order entry) is used in patient care. This integrated review identified 95 papers on the impact of health information technology on the outcomes of residents in older adult care homes. Most papers focused on usability and implementation of technology and the perceptions of staff. Fewer focused on patient quality or safety outcomes.
Ramsey L, McHugh SK, Simms-Ellis R, et al. J Patient Saf. 2022;Epub Aug 2.
Patients and families can contribute unique insights into medical errors. This qualitative evidence review concluded that patients and families value involvement in patient safety incident investigations but highlight the importance of addressing the emotional aspects of care (e.g., timely apology, prioritizing trust and transparency). Healthcare staff perceived patient and family involvement in investigations to be important, but cited several barriers (e.g., staff turnover, fears of litigation) to effective investigations.
Parker H, Frost J, Day J, et al. PLoS ONE. 2022;17:e0271454.
Prophylactic antimicrobials are frequently prescribed for surgical patients despite the risks of antimicrobial overuse (e.g., resistance). This review summarizes how and why antimicrobials continue to be prescribed in surgical settings despite evidence of overuse. Eight overarching concepts were identified: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment.
Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:B2-B10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.
Harrison R, Johnson J, McMullan RD, et al. J Patient Saf. 2022;Epub May 25.
Providers who are involved in a medial error may experience a range of negative emotions and utilize a variety of coping mechanisms following the error. The authors update their 2010 systematic review on medical professionals’ coping with medical error and apply their Recovery from Situations of Error Theory (ReSET) model. The ReSET model provides a basis to develop and evaluate interventions to reduce feelings of distress and increase providers’ coping skills.
Montgomery A, Lainidi O, Johnson J, et al. Health Care Manage Rev. 2022;Epub Jun 16.
When faced with a patient safety concern, staff need to decide whether to speak up or remain silent. Leaders play a crucial role in addressing contextual factors behind employees’ decisions to remain silent. This article offers support for leaders to create a culture of psychological safety and encourage speaking up behaviors.
Morris P, McCloskey R, Bulman D. Innov Aging. 2022;6:iagc028.
Patient-centered care ensures that patient values, needs and preferences are respected; however, some patient populations, such as older adults with dementia, may require assistance. This article describes iatrogenic harm resulting from well-intended assistance in residential long-term care.
Abildgren L, Lebahn-Hadidi M, Mogensen CB, et al. Adv Simul (Lond). 2022;7:12.
Simulation is becoming more common in healthcare education programs, but often focuses on in-hospital, skills-based training aimed at developing team human factors skills. This systematic review included 72 studies from 2004-2021 that included human factors skills with a variety of different designs, types of training interventions, and assessment tools and methods. The authors concluded that simulation-based training was effective in training teams in human factors skills; additional work is needed on the retention and transfer of those skills to practice.
Eldridge N, Wang Y, Metersky M, et al. JAMA. 2022;328:173.
Improving patient safety in hospitals is a longstanding national priority. Using longitudinal Medicare data from 2010 to 2019, this study identified a significant decrease in the rates of adverse events (e.g., adverse drug events, hospital-acquired infections, postoperative adverse events, hospital-acquired pressure ulcers, falls) over time among patients hospitalized for four common conditions – acute myocardial infarction, heart failure, pneumonia, and surgical procedures.
Tajeu GS, Juarez L, Williams JH, et al. J Gen Intern Med. 2022;37:1970-1979.
Racial bias in physicians and nurses is known to have a negative impact on health outcomes in patients of color; however, less is known about how racial bias in other healthcare workers may impact patients. This study used the Burgess Model framework for racial bias intervention to develop online modules related to racial disparities, implicit bias, communication, and personal biases to help healthcare workers to reduce their implicit biases. The modules were positively received, and implicit pro-white bias was reduced in this group. Organizations may use a similar program to reduce implicit bias in their workforce.
Howe LC, Hardebeck EJ, Eberhardt JL, et al. Proc Natl Acad Sci USA. 2022;119:e2007717119.
Providers’ gender, racial, and ethnic bias can adversely affect patient safety and lead to poor outcomes. This study investigated white patients’ physiological responses to treatment provided by either a woman or Black physician. Despite patients’ positive overt attitudes to Black or woman physicians, they were less physiologically responsive to placebo treatment provided by women or Black physicians, suggesting additional implications for health inequities.
Yeh JC, Chae SG, Kennedy PJ, et al. J Pain Symptom Manage. 2022;Epub May 25.
Potentially inappropriate opioid infusion use can result in adverse patient outcomes. This single-site retrospective study found that potentially inappropriate opioid infusions are prevalent (44% of patients receiving opioid infusions during end-of-life care) and were associated with high rates of patient and staff distress.
Marsh KM, Fleming MA, Turrentine FE, et al. J Pediatr Surg. 2022;57:616-621.
Patient safety improvement can be hindered by lack of effective measurement tools. This scoping review explored how medical errors are defined and measured in studies of pediatric surgery patients. The authors identified several evidence gaps, including absence of standardized error definitions.
Strengthening diagnostic error research and training can lead to sustained diagnostic improvement. Expanding upon legislation introduced in 2020, the “Improving Diagnosis in Medicine Act of 2022” would establish research centers of diagnostic excellence, an interagency council on improving diagnosis in healthcare, and fellowship and training grants in diagnostic safety, as well as convene an expert panel on diagnostic error measurement and data collection and prioritize stakeholder engagement across all activities.
Velasco RAF, Slusser K, Coats H. J Adv Nurs. 2022;Epub Jun 10.
Transgender and gender-diverse may experience poor quality of healthcare due to stigma and discrimination. This systematic review of qualitative studies found that stigma experienced among transgender and gender-diverse patients occurs at the individual (e.g., internalized stigma, marginalization), interpersonal (e.g., verbal abuse from healthcare providers, withholding of care), and structural levels (e.g., gender norms, power imbalances).
Goodair B, Reeves A. Lancet Public Health. 2022;7:e638-e646.
England’s National Health Service (NHS) allows patients to receive care from public or for-profit private organizations. In comparing treatable mortality rates at public and for-profit providers, researchers found an additional 557 treatable deaths at for-profit private organizations between 2014 and 2020. The authors recommend further research into potential causes.
Thirsk LM, Panchuk JT, Stahlke S, et al. Int J Nurs Stud. 2022;133:104284.
Biases in healthcare can compromise decision-making and lead to diagnostic errors and delays in diagnosis. This scoping review examines cognitive and implicit biases in nursing care. The authors found a breadth of evidence examining the presence of cognitive and implicit biases in nursing but identified limited evidence evaluating effective debiasing interventions.
Rydenfält C. J Patient Saf Risk Manag. 2022;27:124-128.
Certain processes and routines, such as checklists, are widely used in healthcare settings to improve patient safety. In this article, the author describes two proposed approaches for the study of healthcare safety routines using human factors and a safety-II perspective.
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