Patient handoffs present opportunities for miscommunication and errors. This quasi-experimental study examined the impact of an electronic nursing handover system (ENHS) on patient safety and handover quality among patients both with and without COVID-19 in the intensive care unit (ICU). Findings indicate that the ENHS improved the quality of the handover, reduced handover time, and increased patient safety.

Cognitive biases can impede diagnostic decision-making and contribute to diagnostic delays and patient harm. This study explored the types of cognitive biases contributing to diagnostic errors in emergency rooms in Japan. The most common biases reported were overconfidence, confirmation bias, availability bias, and anchoring bias. Findings indicate that most diagnostic errors involved overlooking another disease in the same organ group or related organ (e.g., diagnosing headache rather than stroke).

Missed and delayed diagnosis are a known cause of preventable adverse events. In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury (AKI). However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed AKI. Involvement of intensive care kidney specialists is recommended to increase diagnostic awareness.

This retrospective study evaluated the impact of a pre-sedation checklist on serious adverse events among children treated with ketamine and propofol in a pediatric emergency department. There were significantly more serious adverse events recorded after the implementation of the checklist.  

This study evaluated the impact of clinical pharmacist-led interventions on medication errors and preventable adverse drug events among patients in the ICU. The clinical pharmacist performed medication chart review, patient monitoring, and attended medical rounds in order to evaluate the appropriateness of the pharmacological treatment, identify and report drug-related issues, and provide evidence-based recommendations for the management of medication errors. When the pharmacist’s recommendations were implemented by prescribing physicians, approximately half of medication errors were intercepted before reaching the patient, resulting in fewer preventable adverse drug events.

This study reports on results of completing TeamSTEPPS training by leadership and staff in the pediatric intensive care unit (PICU) at one hospital in Saudi Arabia. The team implemented a daily safety huddle aimed at improving communication and early identification and timely resolution of patient safety issues. Over a 7-month period, 340 safety issues were addressed; the majority involved infection control and medication errors (32%), communication issues (24%) and documentation issues (17%). The authors observed that the daily huddle addressed misconceptions and misunderstandings between nursing and medical teams leading to improved care delivery.

Medication errors are thought to be common in neonatal intensive care units (NICUs). This study compared the incidence of medication errors occurring in two NICUs over a three-month period. Over the study period, there were an average of 3.38 medication errors per patient and three-quarters of neonates experienced at least one error. Preterm neonates experienced medication errors significantly more often than term neonates. Errors in prescription dosage and administration were the most common errors.

This retrospective study sought to determine whether timely diagnosis of the site of infection affected in-hospital mortality for sepsis. Investigators found that patients whose infection site was misdiagnosed on admission had more than twofold greater odds of dying in the hospital compared to those with the correct infection site diagnosed on admission. These results reinforce the importance of correct and timely diagnosis for sepsis outcomes.

Medication administration mistakes can result in serious patient harm. This review explored human factors that contribute to spinal anesthesia administration errors. The authors documented organizational, supervisory, system, and individual factors that contributed to errors. They recommend strategies to prevent such incidents, including the use of double checks and improved labeling practices.

Autopsies are an underutilized tool for identifying diagnostic errors. Researchers evaluated 117 autopsies for patients in Shanghai whose cause of death was disputed or required third-party investigation. Diagnostic errors that would have altered treatment or survival were found in nearly 61%. This number is higher than estimates from a previous systematic review, likely because all patients in this sample had a disputed cause of death.

This direct observation study of emergency physicians found that interruptions, multitasking, and poor sleep were associated with making more medication prescribing errors. These results add to the evidence that clinical environments prone to interruptions may pose a safety risk.

This observational study found that prescription errors were less frequent in 2007, shortly after computerized physician order entry implementation, than in 2015. Changes to decision support in 2015 led to a subsequent reduction in errors in 2016. The authors argue for surveillance of electronic prescribing in order to detect medication errors.

While prior research has shown that computerized provider order entry and clinical decision support systems have the potential to improve patient safety, less is known about the impact of such systems in intensive care units. In this systematic review and meta-analysis, investigators found an 85% decrease in prescribing errors and a 12% reduction in ICU mortality rates in critical care units that converted from paper orders to commercially available computerized provider order entry systems.

This study reviewed prescriptions following implementation of a computerized provider order entry system. More than half of examined prescriptions had medication errors, most often related to incorrect documentation of verbal orders. These results add to concerns about unintended consequences of computerized provider order entry.

Full-time trauma surgeons had a lower incidence of diagnostic errors (defined as the incidence of missed injuries in severely injured patients) compared with surgeons who primarily practiced in other specialties, according to this retrospective analysis of patients admitted to a Taiwanese surgical intensive care unit.

This research letter examines the value of the physical examination in forming a correct diagnosis on admission. The authors found that four out of five internal medicine patients in the emergency department could be correctly diagnosed from information gleaned by the history, physical examination, and basic laboratory tests.

This study discovered that medication errors were more common in the emergency department setting than in emergency vehicles, and patients requiring multiple medications were at higher risk for medication errors.

The accuracy of medication profiles at a small hospital was superior to that documented in other studies, a finding which the authors attribute to use of an integrated medication reconciliation system within the electronic medical record.

This study discovered that computerized provider order entry saved nurses time but did not improve their ability to detect infusion pump programming errors compared with handwritten orders.

This study evaluated the mechanisms by which hospital wards learned from medication administration errors and the effect these learning strategies had on subsequent incidence of errors.