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.
Ramani S, Halpern TA, Akerman M, et al. Am J Obstet Gynecol. 2022;226:556.e1-556.e9.
Cesarean delivery can lead to adverse outcomes and is commonly used as a measure of obstetrical quality; however, these measures do not account for preexisting maternal and neonatal morbidities, which may increase risk for cesarean delivery. This article describes the development and testing of a new obstetrical quality measure that integrates cesarean delivery rates adjusted for preexisting high-risk maternal factors as well as maternal and neonatal morbidities. Among obstetricians in one large hospital, researchers found that this metric led to significantly different clinician rankings in terms of obstetrical quality (compared to rankings based on crude or adjusted cesarean delivery rates alone.) The authors suggest that this new metric can help identify opportunities for practice improvement among individual clinicians and institutions.
Tate K, McLane P, Reid C, et al. BMJ Open Qual. 2022;11:e001639.
Older adults are vulnerable to patient safety events during care transitions. The Older Persons’ Transitions in Care (OPTIC) study prospectively tracked long-term care residents’ transitions and applied the IOM’s quality of care domains to develop 49 measures for quality of care for the transition process (e.g., safety, timeliness, efficiency, effectiveness, and patient-centered care) between long-term care and emergency department settings.
Navathe AS, Liao JM, Yan XS, et al. Health Aff (Millwood). 2022;41:424-433.
Opioid overdose and misuse continues to be a major public health concern with numerous policy- and organization-level approaches to encourage appropriate clinician prescribing. A northern California health system studied the effects of three interventions (individual audit feedback, peer comparison, both combined) as compared to usual care at several emergency department and urgent care sites. Peer comparison and the combined interventions resulted in a significant decrease in pills per prescription.
Al-Ghunaim TA, Johnson J, Biyani CS, et al. Am J Surg. 2022;224:228-238.
Burnout in healthcare providers has been linked to lower patient safety and increased adverse events. This systematic review examined studies focusing on the relationship between burnout and patient safety and professionalism in surgeons. Results indicate higher rates of burnout and emotional exhaustion were associated with an increased risk of involvement in medical error. Interventions to reduce burnout and improve surgeon well-being may result in improved patient safety.
Dorken Gallastegi A, Mikdad S, Kapoen C, et al. J Surg Res. 2022;274:185-195.
While interoperative deaths (IODs) are rare, they are catastrophic events. This study analyzed five years of data on IODs from a large academic medical center. The authors describe three phenotypes: patients with traumatic injury, those undergoing non-trauma-related emergency surgery, and patients who die during an elective procedure from medical cardiac arrests or vascular injuries. This classification framework can serve as a foundation for future research or quality improvement processes.
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.
Petrosoniak A, Fan M, Hicks CM, et al. BMJ Qual Saf. 2021;30:739-746.
Trauma resuscitation is a complex, specialized process with a high risk for errors. Researchers analyzed videotapes of in situ simulations to evaluate latent safety events occurring during trauma resuscitation. Themes influencing latent safety events related to physical workspace, mental model formation, equipment, unclear accountability, demands exceeding individuals’ capacity, and task-specific issues.
Krancevich NM, Belfer JJ, Draper HM, et al. Ann Pharmacother. 2022;56:52-59.
Prescribing opioids to opioid-naïve patients after hospital discharge may lead to chronic use. This study evaluated long-term opioid use among patients admitted directly to the ICU and who received intravenous opioids. While long-term opioid use was more common among patients who received an opioid prescription at discharge, the authors did not find a significant relationship between ICU opioid prescribing in opioid-naïve patients and long-term opioid use. The authors suggest future research focus on transitions from hospital to home or other post-acute sites to reduce inappropriate opioid use.
Barbash IJ, Davis BS, Yabes JG, et al. Ann Intern Med. 2021;174:927-935.
Starting in 2015, the Centers for Medicare & Medicaid Services has required hospitals to report adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). This study examined sepsis patient encounters at one health system two years before and two years after SEP-1 implementation. Results indicate variable changes in process measures but no improvement in clinical outcomes. The authors suggest revising the measure with more flexible guidelines that allow clinician discretion may improve patient outcomes.
Han D, Khadka A, McConnell M, et al. JAMA Netw Open. 2020;3:e2024589.
Unexpected death or serious disability of a newborn is considered a never event. A cross-sectional analysis including over 5 million births between 2011 and 2017 in the United States found unexpected newborn death was associated with a significant increase in use of procedures to avert or mitigate fetal distress and newborn complications (e.g., cesarean delivery, antibiotic use for suspected sepsis). These findings could reflect increased caution among clinicals or indicate more proactive attempts to identify and address potential complications.
Finney RE, Torbenson VE, Riggan KA, et al. J Nurs Manag. 2021;29:642-652.
Healthcare professionals who experience emotional consequences after adverse events are referred to as ‘second victims’. Nearly half of nurses responding to this survey reported ‘second victim’ events during their career and experienced psychological distress, greater turnover intention, decreased professional self-efficacy, and lack of institutional support. Nurse respondents expressed desires for more peer support interventions for ‘second victim’ experiences.
Donovan AL, Aaronson EL, Black L, et al. Jt Comm J Qual Patient Saf. 2021;47:23-30.
Patient suicide, attempted suicide, or self-harm are considered ‘never events.’ This article describes the development and implementation of a safety protocol for emergency department (ED) patients at risk for self-harm, including the creation of safe bathrooms and increasing the number of trained observers in the ED. Implementation of the protocol was correlated with lower rates of self-harm.
Diagnostic error is an ongoing patient safety challenge, and can be exacerbated by the hectic pace of the emergency department (ED). This study assessed the feasibility of the Leveraging Patient’s Experience to Improve Diagnosis (LEAPED) program to measure patient-reported diagnostic error after ED discharge. Across three EDs, patient uptake of the program was high. Findings show that 23% of patients did not receive an explanation of their health problem upon discharge, and one-quarter of those patients did not understand the next steps after leaving the ED.
Hsu HE, Mathew R, Wang R, et al. JAMA Pediatr. 2020;174:1176-1183.
Catheter-associated urinary tract infections (CAUTI) and central catheter-associated blood stream infections (CLABSI), are common complications in hospitalized patients, particularly among critically-ill children. Using surveillance data from January 2013 to June 2018, the authors did not identify any significant changes in CLABSI rates in NICUs or PICUs. These trends indicate that past gains in CLABSI rates have held, without evidence of further improvement. The authors noted modest improvements in CAUTI rates, observing a significant decrease in CAUTI rates in the PICU, corresponding with a significant decrease in indwelling urinary catheter use.
Pulia M, Wolf I, Schulz L, et al. West J Emerg Med. 2020;21:1283-1286.
Antimicrobial stewardship is one strategy to improve antibiotic use to reduce hospital-acquired infections. In this editorial, the authors discuss negative effects of COVID-19 on antimicrobial resistance and antibiotic stewardship in the emergency department (ED) and approaches for optimizing ED stewardship during the pandemic.
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.
This commentary presents two cases of near-miss wrong-patient order errors between mother-newborn pairs and discusses the unique threat the postpartum setting presents to electronic order safety. The article highlights opportunities for systems improvement.
Myers LC, Heard L, Mort E. Am J Crit Care. 2020;29:174-181.
This study reviewed medical malpractice claims data between 2007 and 2016 to describe the types of patient safety events involving critical care nurses. Decubitus ulcers were the most common diagnosis in claims involving ICU nurses and compared to nurses in emergency departments and operating rooms, ICU nurses were likely to have a malpractice claim alleging failure to monitor.
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