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Baartmans MC, Hooftman J, Zwaan L, et al. J Patient Saf. 2022;Epub Apr 21.
Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.
Marang-van de Mheen PJ, Vincent CA. BMJ Qual Saf. 2021;30:525-528.
Research has shown that patients admitted to the hospital on the weekend may experience worse outcomes compared to those admitted on weekdays (the ‘weekend effect’). This editorial highlights the challenges to empirically evaluate the underlying mechanisms contributing to the weekend effect. The authors propose viewing the weekend effect as a proxy for staffing levels and the influence of other factors influencing outcomes for patients admitted on weekends, such as patient acuity, clinician skill-mix and access to diagnostic tests or other ancillary services.
Rosen IEW, Shiekh RM, Mchome B, et al. Acta Obstet Gynecol Scand. 2021;100:704-714.
Improving maternal safety is an ongoing patient safety priority. This systematic review concluded that maternal near miss events are negatively associated with various aspects of quality of life. Women exposed to maternal near miss events were more likely to have overall lower quality of life, poorer mental and social health, and suffer negative economic consequences.
Lippke S, Derksen C, Keller FM, et al. Int J Environ Res Public Health. 2021;18:2616.
Communication is an essential component of safe patient care. This review of 71 studies found that communication training interventions in obstetrics can improve communication skills and behavior, particularly when combined with team training. The authors identified a lack of evidence regarding the effect of communication trainings on patient safety outcomes and suggest that future research should assess this relationship. Study findings underscore the need for adequate communication trainings to be provided to all staff and expectant mothers and their partners.
Fridrich A, Imhof A, Schwappach DLB. J Patient Saf. 2021;17:217-222.
Checklists are used across clinical areas. Following the publication of the World Health Organization’s (WHO) Surgical Safety Checklist in 2009, other organizations developed their own checklists or adapted the WHO Surgical Safety Checklist for local settings. The authors analyzed 24 checklists used in 18 Swiss hospitals, identified major differences between study checklists and reference checklists and provided recommendations for future research regarding the effectiveness of surgical safety checklists. 
Decormeille G, Maurer-Maouchi V, Mercier G, et al. Crit Care Med. 2021;49:e20-e30.
Common nursing procedures, such as bathing patients in their beds, can result in physiologic changes or accidental displacement of medical devices that may be dangerous to the patient. This study of 254 intensive care patients across Western Europe found that serious adverse events occurred in half of patients during bed bathing.
Avesar M, Erez A, Essakow J, et al. Diagnosis (Berl). 2021;8:358-367.
Disruptive and rude behavior can hinder teamwork and diminish patient safety. This randomized, simulation-based study including attendings, fellows, and residents explored whether rudeness during handoff affects the likelihood for challenging a diagnostic error. The authors found that rudeness may disproportionally hinder diagnostic performance among less experienced physicians.
Ausserhofer D, Zaboli A, Pfeifer N, et al. Int J Nurs Stud. 2020;113:103788.
Emergency department triage systems are intended to prioritize patients based on illness severity, but inappropriate triage can result in delays in care and adverse events. Conducted at a single emergency department (ED) in Italy, this study found that nurse-led triage errors occurred in 16.3% of patients and were associated with longer emergency department and hospital stays.
Pelaccia T, Messman AM, Kline JA. Patient Edu Couns. 2020;103:1650-1656.
The hectic and complex environment of emergency care can reduce diagnostic safety. This article discusses clinical reasoning and decision-making strategies used by emergency medicine physicians, contributing factors to diagnostic errors occurring in emergency medicine (e.g., overconfidence, cognitive stress, anchoring bias), and strategies to reduce the risk of error. A previous WebM&M commentary discussed an incident involving diagnostic delay in the emergency department.
Nygaard AM, Selnes Haugdahl H, Støre Brinchmann B, et al. J Clin Nurs. 2020;29:3822-3834.
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.
Dell-Kuster S, Gomes NV, Gawria L, et al. BMJ. 2020;370:m2917.
This cohort study enrolled 18 sites across 12 countries to assess the validity of a newly developed classification system (ClassIntra v1.0) for assessing intraoperative adverse events. Results indicate that the tool has high criterion validity and can be incorporated into routine practice in perioperative surgical safety checklists or used as a monitoring/reporting tool.
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.  
Koch A, Burns J, Catchpole K, et al. BMJ Qual Saf. 2020;29:1033-1045.
This systematic review evaluated the relationships between intraoperative flow disruptions (eg, interruptions, equipment malfunctions, unexpected patient conditions) and provider, surgical process, and patient outcomes. On average, 20.5% of operating time was attributed to flow disruptions and these disruptions were either negatively or not substantially associated with surgical outcomes. The authors observed substantial heterogeneity of the evidence base and provided recommendations for future research on the effects of flow disruptions in surgery.
Storesund A, Haugen AS, Flaatten H, et al. JAMA Surg. 2020;155:562-570.
This study assessed the impact of combined use of two surgical safety checklists on morbidity, mortality, and length of stay – the Surgical Patient Safety System (SURPASS) is used to address preoperative and postoperative care, and the World Health Organization surgical safety checklist (WHO SSC) is used for perioperative care.  In addition to existing use of the WHO SSC, the SURPASS checklist was implemented in three surgical departments in one tertiary hospital in Norway. Results demonstrated that combined use of these checklists was associated with reduced complications reoperations, and readmissions, but combined use did not impact mortality or length of stay.
Howlett MM, Butler E, Lavelle KM, et al. Appl Clin Inform. 2020;11.
Using a pre-post approach, this study assessed the impact of implementing electronic prescribing and smart pump-facilitated standard concentration infusions on medication errors in a pediatric intensive care unit (PICU). The overall error rates were similar before and after implementation but the error types changed before and after implementation of these tools. After implementation, lack of clarity, incomplete orders and wrong unit errors were reduced but dosing errors, altered orders and duplicate errors increased. Pre-implementation, 78% of errors were deemed preventable by electronic prescribing and smart-pumps; post-implementation 27% of errors were attributed to the technology and would not have occurred if the order was not electronically created or administered via the smart-pump.
Plint AC, Stang A, Newton AS, et al. BMJ Qual Saf. 2021;30:216-227.
This article describes emergency department (ED)-related adverse events in pediatric patients presenting to the ED at a pediatric hospital in Canada over a one-year period.  Among 1,319 patients at 3-months follow-up, 33 patients (2.5%) reported an adverse event related to their ED care.  The majority of these events (88%) were preventable. Most of the events involved diagnostic (45.5%) or management issues (51.5%) and resulted in symptoms lasting more than one day (72.7%).
Anderson JE, Ross AJ, Back J, et al. Int J Qual Health Care. 2020.
Using ethnographic methods and resilient healthcare principles (described as systems that anticipate future demands, respond to current demands, monitor for emergent problems and learn from results, both positive and negative), the researchers interviewed and observed staff in emergency departments (EDs) and geriatric wards in one teaching hospital in London to identify system vulnerabilities to target with quality improvement interventions. The observations and interviews revealed difficulties with discharge planning and information integration as priority areas.
Sanson G, Marino C, Valenti A, et al. Heart & Lung. 2020;49:407-414.
Prospective observational study examined whether nursing complexity level predicts adverse event risk among patients transferred from the ICU to the discharge ward. In this 13-bed ICU, researchers found that various factors including level of acuity and nursing complexity predated risk of adverse events (AEs); patients who exceeded a predetermined complexity threshold were at 3-times greater risk of AEs.
Fernholm R, Holzmann MJ, Wachtler C, et al. BMC Fam Pract. 2020;21.
Much of the evidence about preventable harm in patients with psychiatric illnesses is limited to inpatient psychiatric facilities. This case-control study explores patient-related factors that place patients at an increased risk for patient safety incidents in primary or emergency care. While differences in income, education, and foreign background had some association with preventable harm, researchers found that psychiatric illness nearly doubled the risk of preventable harm among both emergency and primary care patients, with nearly half (46%) of harm attributable to diagnostic errors.
Stengel D, Mutze S, Güthoff C, et al. JAMA Surg. 2020.
The Joint Commission recognizes potential overuse of diagnostic imaging, particularly computed tomographic (CT) scans, to be a patient safety risk due to excess radiation exposure. This study sought to determine whether low-dose whole-body CT (WBCT), which exposes the patient to less radiation, has similar accuracy to standard-dose WBCT. A cohort of over 1,000 patients with suspected blunt trauma were prospectively recruited; half received standard-dose WBCT and the other half received low-dose WBCT.  The authors found that use of low-dose WBCT did not increase risk of missed injury diagnosis, while reducing median radiation exposure by almost half.