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Weston M, Chiodo C. AORN J. 2022;115:569-575.
Unintentionally retained foreign objects can be exacerbated by fatigue, distractions, and communication errors. This article highlights the importance of effective teamwork, high reliability orientation, and standardized surgical count methods to minimize the persistent problem of retained surgical items.
Howell EA, Sofaer S, Balbierz A, et al. Obstet Gynecol. 2022;139:1061-1069.
Health equity in maternal safety is a major patient safety goal. Researchers interviewed health care professionals, including frontline nurses and physicians, chief medical officers, and quality and safety officers, from high- and low-performing hospitals. Six themes emerged differentiating high and low performers: 1) senior leadership involved in day-to-day quality activities and dedicated to quality improvement, 2) a strong focus on standards and standardized care, 3) strong nurse-physician communication and teamwork, 4) adequate physician and nurse staffing and supervision, 5) sharing of performance data with nurses and other frontline clinicians, and 6) explicit awareness that racial and ethnic disparities exist and that racism and bias in the hospital can lead to differential treatment. PSNet offers a Patient Safety Primer and Curated Library on maternal safety.
Nanji K. UpToDate. June 23, 2022.
Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical setting and discusses prevention strategies that focus on medication reconciliation, technology, standardization, and institutional change.
Wooldridge AR, Carayon P, Hoonakker PLT, et al. Hum Factors. 2022;Epub Jun 5.
Handoffs between inpatient care settings represent a vulnerable time for patients. This qualitative study explores how team cognition occurs during care transitions and interprofessional handoffs between inpatient settings and the influence of sociotechnical systems, such as communication workflows or electronic heath record-based interfaces) influence team cognition. Participants highlighted how interprofessional handoffs can both enhance (e.g., information exchange) and hinder (e.g., logistic challenges and imprecise communication) team cognition.
Krenzischek DA, Card E, Mamaril M, et al. J Perianesth Nurs. 2022;Epub Apr 27.
Patients and caregivers are important partners in promoting safe care. Findings from this cross-sectional study reinforce the importance of patients’ perceived roles in ensuring safe surgery and highlight the importance of patient engagement in mitigating surgical site errors.
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.
Ulmer FF, Lutz AM, Müller F, et al. J Patient Saf. 2022;18:e573-e579.
Closed-loop communication is essential to effective teamwork, particularly during complex or high-intensity clinical scenarios. This study found that participation in a one-day simulation team training for pediatric intensive care unit (PICU) nurses led to significant improvements in closed-loop communication in real-life clinical situations.
Patel SJ, Ipsaro A, Brady PW. Hosp Pediatr. 2022;Epub Feb 28.
Diagnostic uncertainty can arise in complex clinical scenarios. This qualitative study explored how physicians in pediatric emergency and inpatient settings mitigate diagnostic uncertainty. Participants discussed common mitigation strategies, such as employing a “diagnostic pause.” The authors also noted outstanding gaps regarding communicating diagnostic uncertainty to families.
Olsen SL, Søreide E, Hansen BS. J Patient Saf. 2022;Epub Apr 4.
Rapid response systems (RRS) are widely used to identify signs of rapid deterioration among hospitalized patients.  Using in situ simulation, researchers identified obstacles to effective RRS execution, including inconsistent education and documentation, lack of interpersonal trust, and low psychological safety.
Derksen C, Kötting L, Keller FM, et al. Front Psychol. 2022;13:771626.
Effective communication and teamwork are fundamental to ensure safe patient care. Building on their earlier systematic review of communication interventions in obstetric care, researchers developed and implemented a training to improve communication at two obstetric hospitals. While results did not show a change in communication behavior, perceived patient safety did improve. Additional resources are available in the curated library on maternal safety.
Howlett O, Gleeson R, Jackson L, et al. JBI Evid Synth. 2022;Epub Mar 4.
Rapid response teams are designed to provide emergency medical support to deteriorating hospitalized patients. This review examines the role of a family support person (FSP) as part of the rapid response team. The FSP supported the family during the resuscitation in numerous ways, such as explaining jargon and medical procedures and attending to the practical needs of the family.

Lane S, Gross M, Arzola C, et al. Can J Anaesth. Epub 2022 Mar 22.

Intraoperative anesthesia handovers can increase patient safety risks. Based on video-recorded handovers and anesthetic records, researchers at this tertiary care center found that introduction of an intraoperative handover checklist improved handover completeness, which may decrease risk for adverse events.
Vollam S, Gustafson O, Morgan L, et al. Crit Care Med. 2022;50:1083-1092.
This mixed-method study explored the reasons why out-of-hours discharges from the ICU to the ward, and nighttime coverage are associated with poor outcomes. Based on qualitative interviews with patients, family members, and staff involved in the ICU discharge process, this study found that out-of-hours discharges are considered unsafe due to nighttime staffing levels and skill mix. Out-of-hours discharges often occurred prematurely, without adequate handovers, and involved patients who were not physiologically stable, and at risk for clinical deterioration.
Mahomedradja RF, van den Beukel TO, van den Bos M, et al. BMC Emerg Med. 2022;22:35.
The potential for medication errors may increase due to redeployment and reorganization of hospital resources during COVID-19 surges. In this study of patients hospitalized during the first wave of the pandemic, over 90% had at least one prescribing error three months after hospitalization. Intensive care unit admission and a history of chronic obstructive pulmonary disease (COPD) or asthma were risk factors for prescribing errors. Acknowledging and understanding these risk factors allows hospital leadership to target interventions for this population.
Shafer GJ, Singh H, Thomas EJ, et al. J Perinatol. 2022;Epub Mar 4.
Patients in the neonatal intensive care unit (NICU) are at risk for serious patient safety threats. In this retrospective review of 600 consecutive inborn NICU admissions, researchers found that the frequency of diagnostic errors among inborn NICU patients during the first seven days of admission was 6.2%.
Andersen TS, Gemmer MN, Sejberg HRC, et al. Pharmaceuticals (Basel). 2022;15:142.
Conducting a complete medication reconciliation in the emergency department may be difficult or even impossible if the patient is unable to speak for themselves. In these instances, clinicians must rely solely on electronic records of medication prescriptions, which do not always reflect the medications being taken. This analysis of prescriptions entered into the Danish Shared Medication Record (SMR) and patient reports of medications taken showed 81% of patients had at least one discrepancy, the most common of which was discontinued medications still showing in the SMR.
Weiseth A, Plough A, Aggarwal R, et al. Birth. 2022;Epub Mar 1.
Labor and delivery is a high-risk care environment. This study evaluated a quality improvement initiative (TeamBirth) designed to promote shared decision-making and safety culture in labor and delivery. This mixed-methods study included both clinicians and patients at four hospitals and found that the program was feasible, increased the use of huddles, and had no negative effects on patient safety.
Etheridge JC, Moyal-Smith R, Sonnay Y, et al. Int J Surg. 2022;98:106210.
Non-technical skills such as communication, teamwork, decision-making, and situational awareness are responsible for a significant proportion of surgical errors. The COVID-19 pandemic increased the stress in the operating room, associated with increased risk of exposure and shortage of resources. This study compared pre- and post-COVID direct observations during live operations and found that non-technical skills were equivalent; there was a small, but statistically significant, improvement in teamwork and cooperation skills.
Hüner B, Derksen C, Schmiedhofer M, et al. Healthcare (Basel). 2022;10:97.
Labor and delivery units are high-risk care environments. Based on a retrospective review of obstetrical adverse events occurring at one German hospital in 2018, researchers created a matrix of preventable factors contributing to adverse events. Six categories of preventable events were identified (peripartum therapy delay; diagnostic error; inadequate maternal birth position; organizational errors; inadequate fetal monitoring; medication error) and 19 associated risk factors, including language barriers, missed diagnosis of a preexisting condition, and on-call duty.
Wooldridge AR, Carayon P, Hoonakker PLT, et al. Appl Ergon. 2022;98:103606.
Care transitions can increase the risk of patient safety events. Using the Systems Engineering Initiative for Patient Safety (SEIPS) model, this study explored care transitions between operating rooms and inpatient critical care units and the importance of articulation work (i.e., preparation and follow-up activities related to transitions) to ensure safe transitions.