Walther F, Schick C, Schwappach DLB, et al. J Patient Saf. 2022;Epub May 4.
Historically, there have been many patient safety errors associated with healthcare workers’ failure to speak up and report when they notice a problem. Many studies have identified organizational culture as important in creating a safe environment for workers to report medical errors. This study reports on a multimodal program to educate and train healthcare workers resulting in improvements on speaking up behaviors.
Dzisko M, Lewandowska A, Wudarska B. Sensors (Basel). 2022;22:3536.
Interruptions and distractions in healthcare settings can inhibit safe care. This simulation study found that medical staff reaction time to changes in vital signs during stressful situations (telephone ringing, ambulance signal) was significantly slower than during non-stressful situations, which may increase the likelihood of medical errors.
Serou N, Slight RD, Husband AK, et al. J Patient Saf. 2022;18:358-364.
Operating rooms are high-risk healthcare settings. This study reviewed serious surgical incidents occurring at large teaching hospitals in one National Health Service (NHS) trust. The authors outline several possible contributing factors (i.e., equipment and resource factors, team factors, work environment factors, and organizational and management factors) discuss recommendations for safer care.
Aranaz-Ostáriz V, Gea-Velázquez De Castro MT, López-Rodríguez-Arias F, et al. Int J Environ Res Public Health. 2022;19:4761.
Preventable adverse events (AE) can occur across medical settings. This study of patients admitted to a surgical ward in Spain compared rates of AE in operated and non-operated patients. Operated patients were more than twice as likely to experience an AE compared with non-operated patients. The most common AE was infection following surgery, affecting 24% of operated and 9% of non-operated patients.
Massart N, Mansour A, Ross JT, et al. J Thorac Cardiovasc Surg. 2022;163:2131-2140.e3.
Surgical site infections and other postoperative healthcare-acquired infections (HAIs) can lead to significant patient morbidity and mortality. This retrospective study examined the relationship between HAIs after cardiac surgery and postoperative inpatient mortality. Among 8,853 patients undergoing cardiac surgery in one academic hospital in France, 4.2% developed an HAI after surgery. When patients developing an HAI were matched with patients who did not, the inpatient mortality rate was significantly greater among patients with HAIs (15.4% vs. 5.7%).
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.
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.
Morsø L, Birkeland S, Walløe S, et al. Jt Comm J Qual Patient Saf. 2022;48:271-279.
Patient complaints can provide insights into safety threats and system weaknesses. This study used the healthcare complaints analysis tool (HCAT) to identify and categorize safety problems in emergency care. Most problems arose during examination/diagnosis and frequently resulted in diagnostic errors or errors of omission.
Armstrong BA, Dutescu IA, Nemoy L, et al. BMJ Qual Saf. 2022;31:463-478.
Despite widespread use of surgical safety checklists (SSC), its success in improving patient outcomes remains inconsistent, potentially due to variations in implementation and completion methods. This systematic review sought to identify how many studies describe the ways in which the SSC was implemented and completed, and the impact on provider outcomes, patient outcomes, and moderating factors. A clearer positive relationship was seen for provider outcomes (e.g., communication) than for patient outcomes (e.g., mortality).
Staal J, Speelman M, Brand R, et al. BMC Med Educ. 2022;22:256.
Diagnostic safety is an essential component of medical training. In this study, medical interns reviewed six clinical cases in which the referral letters from the general practitioner suggested a correct diagnosis, an incorrect diagnosis, or lacked a diagnostic suggestion. Researchers found that diagnostic suggestions in the referral letter did not influence subsequent diagnostic accuracy but did reduce the number of diagnoses considered.
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.
Organizational, environmental, and work-related factors can contribute to performance variations and human error during healthcare delivery. This study examined perioperative sentinel events reported to a Dutch database over a one-year period. It found that although performance variability continued in almost all events, it was rarely explicitly mentioned in incident reports or represented in resulting improvement measures. The authors suggest that explicitly addressing performance variability in sentinel event analyses can lead to more effective improvement measures that account for human performance in healthcare.
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.
Dieckmann P, Tulloch S, Dalgaard AE, et al. BMC Health Serv Res. 2022;22:307.
When staff feel psychologically safe, they are more likely to speak up about safety concerns. This study sought to explore the link between psychological safety and improvement work, and whether an existing model captures all the relevant ‘antecedents’ and ‘consequences’ of psychological safety.
Fuchs A, Frick S, Huber M, et al. Anaesthesia. 2022;77:751-762.
Pre-procedure checklists have been shown to improve patient safety but they are still not utilized in all situations. Analysis of five years of airway management checklist use in operating room, non-operating room, and emergency procedures showed increasing adherence to checklist use, but completion varied by time of day, location, and urgency of procedure. Further research into causes for these variations is recommended.
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.
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.
Pérez Zapata AI, Rodríguez Cuéllar E, de la Fuente Bartolomé M, et al. Patient Saf Surg. 2022;16:7.
Trigger tools are one method of retrospectively detecting adverse events. In this study, researchers used data from 31 Spanish hospitals to validate a trigger tool in general and gastrointestinal surgery departments. Of 40 triggers, 12 were identified for optimizing predictive power of the trigger tool, including broad spectrum antibiotherapy, unscheduled postoperative radiology, and reintervention.
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.
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