Della Torre V, E. Nacul F, Rosseel P, et al. Anaesthesiol Intensive Ther. 2021;53(3):265-270.
Human factors (HF) is the interaction between workers, equipment, and the environment. The COVID-19 pandemic has accelerated the adoption of HF in intensive care units across the globe. This paper expands on the core concepts of HF and proposes the additional key concepts of agility, serendipity, innovation, and learning. Adoption of these HF concepts by leadership and staff can improve patient safety in intensive care units in future pandemics and other crisis situations.
Carvalho IV, Sousa VM de, Visacri MB, et al. Pediatr Emerg Care. 2021;37(4):e152-e158.
This study sought to determine the rate of pediatric emergency department (ED) visits due to adverse drug events (ADE). Of 1,708 pediatric patients, 12.3% were admitted to the ED due to ADEs, with the highest rates of admission due to neurological, dermatological, and respiratory medications. The authors recommend the involvement of clinical pharmacists to prevent and identify ADEs in the pediatric population, particularly through education of children’s caregivers and health professionals.
Camporesi A, Díaz‐Rubio F, Carroll CL, et al. J Paediatr Child Health. 2020;56(7):1010-1012.
This commentary discusses changes in critical care practice as a response to COVID-19, and the potential for iatrogenic harm to children when diverting from evidence-based medicine during the pandemic crisis.
Barbanti-Brodano G, Griffoni C, Halme J, et al. Eur Spine J. 2019.
Checklists are one tool for improving communication and reducing risk of adverse outcomes. The World Health Organization Surgical Safety Checklist has been previously studied in various surgical specialties; this study sought to determine its effectiveness in spinal surgeries. The authors conducted a retrospective analysis comparing the incidence of complications pre-checklist and post-checklist in a single center and found a significant reduction in the overall incidence of complications after the introduction of the checklist.
Lemos C de S, Poveda V de B. J Perianesth Nurs. 2019;34:978-998.
This integrative review examined the factors contributing to perioperative adverse events resulting from anesthesia. Researchers found that both active errors, such as medication errors or inattention, and latent errors, such as communication failures, contributed to adverse events.
Garcia C de L, de Abreu LC, Ramos JLS, et al. Medicina (Kaunas). 2019;55.
New meta-analysis on potential impacts of provider burnout concludes a relationship exists between high levels of burnout—from factors such as high workload and ineffective interpersonal relationships—and worsening patient safety.
Lermontov SP, Brasil SC, de Carvalho MR. Cancer Nurs. 2019;42:365-372.
Bone marrow transplantation requires complex drug therapy management. This systematic review identified 11 studies reporting both medication prescription and administration errors, as well as issues such illegible writing, polypharmacy, absence of medication reconciliation, and lack of patient education. These errors resulted in a variety of adverse events. The review identified several prevention measures that can be implemented at the provider-level or systems-level (e.g., computerized prescribing systems).
Freitas PS, Silveira RC de CP, Clark AM, et al. J Clin Nurs. 2016;25:1835-47.
Retained surgical items are considered a never event, but they continue to occur. Summarizing the evidence on surgical counts, this review explores risk factors, current processes, and technology solutions to determine best practices for perioperative nurses to prevent instances of retained surgical items.
Otero P, Leyton A, Mariani G, et al. Pediatrics. 2008;122:e737-43.
This study examined medication error rates before and after implementation of interventions targeted toward an improved safety culture. Investigators demonstrated a modest but significant reduction in error prevalence.
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