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Validation of the second victim experience and support tool-revised in the neonatal intensive care unit.

Winning AM, Merandi J, Rausch JR, et al. J Patient Saf. 2021;17(8):531-540.

Healthcare professionals involved in a medical error often experience psychological distress. This article describes the validation of a revised version of the Second Victim Experience and Support Tool (SVEST-R), which was expanded to include measures of resilience and desired forms of support.

The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps

January 7, 2022

A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several different providers (pre-operative nurse, resident physician, attending physician, and anethesiology team) to help prepare her for the procedure. In the OR, the surgical team performed two separate time-outs while the patient was being prepped, placed under general anesthesia, and draped.

Maternal mortality: near-miss events in middle-income countries, a systematic review.

Heitkamp A, Meulenbroek A, van Roosmalen J, et al. Bull World Health Organ. 2021;99(10):693-707F.

Maternal safety is a patient safety priority. According to this systematic review including 69 studies, the maternal near miss incidence rate is estimated to be 15.9 cases per 1,000 live births in lower-middle income countries and 7.8 cases per 1,000 live births in upper-middle-income countries. The most common causes of near miss were obstetric hemorrhage and hypertensive disorders.

Application of human factors methods to ensure appropriate infant identification and abduction prevention within the hospital setting.

Webster KLW, Stikes R, Bunnell L, et al. J Perinat Neonatal Nurs. 2021;35(3):258-265.

Infant misidentification or abduction are considered never events. This article discusses the results of a failure mode and effects analysis to identify and eliminate or reduce the risk of infant misidentification or abduction. Twenty-eight failure modes were identified; the highest-ranked items involved concerns for uninvited individuals on the unit, interactions with child-protective services, alarm fatigue, and inadequate identification checks of the infants with mothers.

Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United States operating rooms.

Weprin SA, Meyer D, Li R, et al. Patient Saf Surg. 2021;15(1):14.

A retained surgical sharp (RSS) is a never event. Operating room (OR) team members, including surgeons, anesthesiologists, and nurses, were surveyed regarding their experiences with actual and near-miss sharps (NMS). While nearly all team members reported experiencing at least one RSS or NMS in the past year, responses to other survey items varied by professional group. Surgeons were less likely to perceive that a sharp had been lost as compared to other OR team members, indicating a potential under-report bias. Improved communication between team members may increase identification, and therefore reporting, of RSS and NMS, to prevent similar incidents in the future.

Quality of life after maternal near miss: a systematic review.

Rosen IEW, Shiekh RM, Mchome B, et al. Acta Obstet Gynecol Scand. 2021;100(4):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.

An Inadvertent Bolus of Norepinephrine.

May 26, 2021

A 64-year-old woman was admitted to the hospital for aortic valve replacement and aortic aneurysm repair. Following surgery, she became hypotensive and was given intravenous fluid boluses and vasopressor support with norepinephrine. On postoperative day 2, a fluid bolus was ordered; however, the fluid bag was attached to the IV line that had the vasopressor at a Y-site and the bolus was initiated.

"Good catch, Kiddo"--enhancing patient safety in the pediatric emergency department through simulation.

Shaikh U, Natale JAE, Till DA, et al. Pediatr Emerg Care. 2022;38(1):e283-e286.

Incident reporting systems may be underutilized by medical trainees. This article describes a brief, interactive simulation activity to improve identification and reporting of patient safety hazards among medical students and interns.

Lack of Sepsis Recognition Leads to Delay in Care Following Cesarean Delivery.

November 25, 2020

After a failed induction at 36 weeks, a 26-year-old woman underwent cesarean delivery which was complicated by significant postpartum hemorrhage. The next day, the patient complained of severe perineal and abdominal pain, which the obstetric team attributed to prolonged pushing during labor. The team was primarily concerned about hypotension, which was thought to be due to hypovolemia from peri-operative blood loss. After several hours, the patient was transferred to the medical intensive care unit (ICU) with persistent hypotension and severe abdominal and perineal pain. She underwent surge

Medication errors in anesthesiology: is it time to train by example? Vignettes can assess error awareness, assessment of harm, disclosure, and reporting practices.

Duffy CC, Bass GA, Duncan JR, et al. J Patient Saf. 2022;18(1):16-25.

Incident reporting systems are central to most patient safety programs, but studies have identified barriers to effective use. This study used clinical vignettes describing a medication error or near miss to explore error awareness and attitudes towards reporting and disclosure among anesthesiologists. Approximately one-third of anesthesiologists recalled having had medication safety training. Perioperative medication error awareness and assessment of potential harm were variable, and the likelihood of patient disclosure and incident reporting was low. Education programs utilizing vignettes should be utilized to raise awareness about error reporting and disclosure behaviors.

Wrong-patient ordering errors in peripartum mother-newborn pairs: a unique patient-safety challenge in obstetrics.

Kern-Goldberger AR, Adelman J, Applebaum JR, et al. Obstet Gynecol. 2020;136(1):161-166.

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.

Effect on patient safety of a resident physician schedule without 24-hour shifts.

Landrigan CP, Rahman SA, Sullivan JP, et al. N Engl J Med. 2020;382(26):2514-2523.

This multicenter cluster randomized trial explored the impact of eliminating extended-duration work schedules (shifts in excess of 24 hours) on serious medical errors made by residents in the pediatric intensive care unit (ICU). The authors found that residents in ICUs which eliminated extended shifts in favor of day and night shifts of 16 hours or less made significantly more serious errors than residents assigned to extended-duration work schedules. The authors observed that the resident-to-patient ratio was higher during schedules which eliminated extended shifts, but also that these results might have been confounded by concurrent increases in workload in ICUs eliminating extended shifts.

Incidence of wrong-site surgery list errors for a 2-year period in a single national health service board.

Geraghty A, Ferguson L, McIlhenny C, et al. J Patient Saf. 2020;16.

Operating room list errors are often cited as leading to wrong-side, wrong-site or wrong-procedure errors. This retrospective study analyzed two years of data from the United Kingdom and found that while no wrong-side, wrong-site or wrong-procedure surgeries were performed during the period, 0.29% of cases (86 cases) included a list error. Wrong-side list errors accounted for the majority of all list errors (72%). Tracking and reducing operating room list errors may help to prevent wrong-side, -site, or -procedure errors.

Misidentifying the Unidentified – John Doe and the EHR

October 30, 2019

Two patients arrived at the Emergency Department (ED) at the same time with major trauma. Both patients were unidentified and were given "Doe" names. Patient 1 was quickly sent to the operating room (OR) but the ED nurse incorrectly gave him Patient 2's "Doe" name. The OR nurse only realized there was a problem when blood arrived with Patient 1's correct "Doe" name, requiring multiple phone calls with the ED, laboratory, and surgeon to correctly identify the patient.

Good Catch in the Operating Room

May 1, 2019

An elderly man with a complicated medical history slipped on a rug at home, fell, and injured his hip. Emergency department evaluation and imaging revealed no head injury and a left intertrochanteric hip fracture. Although he was admitted to the orthopedic surgery service with surgery to fix the fracture initially scheduled for the next day, the operation was delayed by 3 days due to several emergent trauma cases and lack of surgeon availability. He ultimately underwent surgery and was discharged a few days later but was readmitted several weeks later with chest pain and shortness of breath.

Perioperative medication errors: uncovering risk from behind the drapes.

Cierniak KH; Gaunt MJ; Grissinger M.

The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.

Using good catches to promote a just culture and perioperative patient safety.

Monahan JJ. AORN J. 2018;108(5):548-552.

The good catch, or near miss, can provide a key learning experience in health care practice. This article discusses the importance of organizational culture in utilizing these experiences as improvement opportunities. The author reviews strategies for nurses to engage in skill development through case review of good catches.

Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.

Neily J, Soncrant C, Mills PD, et al. JAMA Netw Open. 2018;1(7):e185147.

The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.

Pharmacist outpatient prescription review in the emergency department: a pediatric tertiary hospital experience.

Shah D, Manzi S. Pediatr Emerg Care. 2018;34:497-500.

Clinical pharmacist supervision improves medication safety in many health care settings. In this study, pharmacists in a pediatric emergency department (ED) reviewed all discharge prescriptions the day after patients left the ED and contacted prescribers to address safety hazards. Over a 1-year period, pharmacists intervened rarely (0.25% of prescriptions), averted 10 incidents of moderate or major harm, and worked 45 additional minutes per day.

Good Catch Campaign: improving the perioperative culture of safety.

Lozito M, Whiteman K, Swanson-Biearman B, et al. AORN J. 2018;107:705-714.

This quality improvement initiative developed and promoted reporting of good catches—recognition of incipient patient safety problems—in the perioperative setting. The authors reported improvement in safety culture scores, as measured by the AHRQ Hospital Survey on Patient Safety Culture, after implementation of the program compared to prior scores.

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