FitzGerald C, Mumenthaler C, Berner D, et al. BMC Med Ethics. 2022;23:86.
Patients with obesity and mental illness face both explicit and implicit bias that negatively impact their healthcare. This study of psychiatric and general internal medicine physicians analyzed implicit and explicit bias towards patients with mental illness and/or obesity. Results varied by specialty, physician age, gender, and experience level.
Suneja M, Beekmann SE, Dhaliwal G, et al. Diagnosis (Berl). 2022;9:332-339.
Delayed diagnosis of infectious diseases can lead to serious patient harm. This survey of over 500 infectious disease clinicians revealed that diagnostic delay often involved diagnoses of infective endocarditis and epidural abscesses. Respondents identified several factors contributing to diagnostic delays including usual clinical presentations and the timing of infectious disease consultations.
Keller C. Health Aff (Millwood). 2022;41:1353-1356.
Communication failures due to hierarchy and silos create opportunities for adverse medication and treatment events. This narrative essay discusses gaps in care coordination that contributed to anticoagulant medication errors. The author outlines areas for improvement such as assignment of accountability for error and commitment to the learning health system as avenues for improvement.
Disruptive behavior includes behaviors that show disrespect for others and impede safe delivery of patient care. This commentary presents a framework for new physician managers to address disruptive behavior modeled after clinical medicine: diagnose, treat, prevent. The authors stress maintaining curiosity during the “diagnostic” phase, careful consideration of “treatment” and follow-up, and “prevention” of future disruption though intentional training and building a culture of safety.
Trigger tools alert patient safety personnel to potential adverse events (AE) which can then be followed up with retrospective chart review. This review sought to understand the variability in adverse event detection in acute care and study characteristics that may explain the variation. Fifty-four studies were included with a wide range of AEs detected per 100 admissions. The authors suggest developing guidelines for studies reporting on AEs identified using trigger tools to decrease study heterogeneity.
Harris CK, Chen Y, Yarsky B, et al. Acad Pathol. 2022;9:100049.
Physicians, including resident physicians, report safety events at lower rates than nurses and other staff. This study analyzed adverse event and near miss reporting by residents in one American hospital. Although pathology residents accounted for more than 5% of residents in the hospital, they only accounted for 0.5% of all reports.
Adair KC, Heath A, Frye MA, et al. J Patient Saf. 2022;18:513-520.
Psychological safety (PS) is integral to ensuring healthcare workers feel comfortable asking questions and raising patient safety concerns. A novel PS assessment was administered to over 10,000 healthcare workers and support staff in one academic health system. The scale showed a significant correlation with safety culture, especially among those exposed to institutional PS programs (i.e., Safety WalkRounds and Positive Leadership WalkRounds).
Patients can be vulnerable to having concerns dismissed or being gaslighted as to their legitimacy. Implicit biases against women in both clinical and administrative settings are known to foster conditions for unsafe care. This piece defines the use of the term gaslighting and how it can result in diagnostic delay due to a lack of patient-centered communication and respect.
Apodaca C, Casanova-Perez R, Bascom E, et al. J Am Med Inform Assoc. 2022;Epub Aug 19.
Minoritized patients who experience implicit or overt discrimination in healthcare report receiving lower quality of care and may avoid seeking care in the future altogether. In this study, patients who identify as Black, Indigenous, People of Color (BIPOC), and/or Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) describe their experiences of unfair treatment and discrimination in healthcare. Four themes related to immediate reactions and six themes related to long-term coping emerged.
Linzer M, Sullivan EE, Olson APJ, et al. Diagnosis (Berl). 2022;Epub Aug 22.
Challenging working conditions and increased cognitive workload can result in stress and burnout. This article describes a conceptual framework in which working conditions and cognitive workload impact stress and burnout, which, in turn, impacts diagnostic accuracy. Potential uses and testing of the framework are described.
Calhoun A, Genao I, Martin A, et al. Acad Med. 2022;97:790-792.
Terminology can negatively influence commitment to change that drives improvement effort success. This commentary discusses the weaknesses of the term “implicit bias,” in that it is too general in nature to result in tangible reduction of structural racism in health care.
Villa Zapata L, Subbian V, Boyce RD, et al. Stud Health Technol Inform. 2022;290:380-384.
Computerized decision support systems can alert clinicians to drug-drug interactions (DDIs), but the alert fatigue contributes to alert overrides. This scoping review includes 34 studies from the United States and international settings and identified a high prevalence of DDI alert overrides. The authors discuss the need for improved decision support systems to improve DDI alerts and actionable metrics to measure harms associated with alert overrides.
Adler-Milstein J, Sarkar U, Wachter RM. J Patient Saf Risk Manag. 2022;27:160-162.
Electronic health records (EHR) house and provide access to a plethora of data to inform care and management decisions. This commentary suggests that EHRs have yet to be fully embraced as a tool to proactively identify areas of risk that could lead to legal action.
Potentially inappropriate prescribing (PIP) among older adults is common and can result in medication-related harm. This narrative review summarizes the evidence on the association between potential frailty and PIP. The authors identified several challenges in measuring and reducing the risks of PIP, including the need for user-friendly methods to rapidly and accurately identify frailty in older adults at risk of PIP.
Plunkett A, Plunkett E. Paediatr Anaesth. 2022;Epub Jun 18.
Safety-I focuses on identifying factors that contribute to incidents or errors. Safety-II seeks to understand and learn from the many cases where things go right, including ordinary events, and emphasizes adjustments and adaptations to achieve safe outcomes. This commentary describes Safety-II and complementary positive strategies of patient safety, such as exnovation, appreciative inquiry, learning from excellence, and positive deviance.
Rehder KJ, Adair KC, Eckert E, et al. J Patient Saf. 2022;Epub Aug 10.
Teamwork is an essential component of patient safety. This cross-sectional study of 50,000 healthcare workers in four large US health systems found that the teamwork climate worsened during the COVID-19 pandemic. Survey findings indicate that healthcare facilities with worsening teamwork climate had corresponding decreases in other measured domains, including safety climate and healthcare worker well-being. The researchers suggest that healthcare organizations should proactively increase team-based training to reduce patient harm.
Olans RD, Olans RN, Marfatia R, et al. Jt Comm J Qual Patient Saf. 2022;48:552-558.
Inadequate or incorrect documentation of patient allergies can lead to patient harm. This commentary discusses factors contributing to penicillin allergy documentation errors within electronic heath record systems (EHRs) and how EHR alerts can be used to improve safety around penicillin allergies.
Neely J, Sampath R, Kirkbride G, et al. J Correct Health Care. 2022;28:141-147.
Incarcerated individuals face unique patient safety threats. Based on a collaboration between the Illinois Department of Corrections and the University of Illinois College of Nursing, this article describes a plan for improving the quality and safety of healthcare for the state’s incarcerated population.
Clinician well-being has important implications for patient safety and quality of healthcare delivery. In this study, researchers used a concept analysis to identify attributes of nurse well-being at the individual level (e.g., satisfaction, compassion) and organizational/community level (e.g., teamwork, pride in work). These findings can support the development of a standardized definition of nurse well-being to guide future research and policy considerations around well-being and burnout.
Radiological interpretation errors can result in unnecessary additional tests, wrong treatment and delayed diagnosis. This study explored the correlation between neuroradiologists’ diagnostic errors and attendance at institutional tumor boards. Results show that higher attendance at tumor boards was strongly correlated with lower diagnostic error rates. The researchers recommend increased and continuous attendance at tumor boards for all neuroradiologists.
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