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Hofer IS, Cheng D, Grogan T. Anesth Analg. 2021;133(3):698-706.
Anesthesia-related adverse events have been associated with increased length of stay, morbidity and mortality. This study investigated the effect of missed documentation of select comorbidities on postoperative length of stay and mortality. Results indicate that missed documentation of one of the comorbid conditions increased risk of length of stay, and mortality was increased with missed atrial fibrillation.

NHSX, NHS Digital, NHS England, et al. London, England: Crown Copyright; September 2021.

Digital clinical technologies hold promise for care improvement while contributing to potential failures due to the lack of collective guidance to assess and measure if they are safe. This document provides background on digital safety. It shares an approach that aligns with the United Kingdom system safety strategy to situate its priorities and support the strategy.
Lafferty M, Harrod M, Krein SL, et al. J Am Med Inform Assoc. 2021;Epub Sep 28.
Use of one-way communication technologies, such as pagers, in hospitals have led to workarounds to improve communication. Through observation, shadowing, interviews, and focus groups with nurses and physicians, this study describes antecedents, types, and effects of workarounds and their potential impact on patient safety.
Winters BD, Slota JM, Bilimoria KY. JAMA. 2021;326(12):1207.
Alarm fatigue is a pervasive contributor to distractions and error. This discussion examines how, while minimizing nuisance alarms is important, those efforts need to be accompanied by safety culture enhancements to realize lasting progress toward alarm reduction.
Slikkerveer M, van de Plas A, Driessen JHM, et al. J Patient Saf. 2021;17(7):e587-e592.
Anticoagulants, such as low-molecular-weight heparin (LMWH), are known to be high-risk for adverse drug events. This cross-sectional study identified prescribing errors – primarily lack of dosage adjustment for body weight and/or renal function – among one-third of LMWH users admitted to one hospital over a five-month period.
Hendrickx I, Voets T, van Dyk P, et al. J Med Internet Res. 2021;23(7):e19064.
Prioritization of patient complaints allows inspectors to follow up more quickly on those that pose the most severe safety risk. Using text mining and sentiment analysis, more than 22,000 patient complaints were assigned a severity category. The ‘bag-of-words representation’ was most successful for severity predicting and could be used to triage patient complaints.
Gluschkoff K, Kaihlanen A, Palojoki S, et al. Safety Sci. 2021;144:105450.
Organizational culture can influence whether or not clinicians report patient safety incidents. Nurses were surveyed about their experiences with non-reporting of health information technology (HIT)-related safety incidents. Approximately half of respondents indicated that they did not file a report when encountering an HIT-related incident. The authors suggest strengthening organizational culture may increase reporting.
Morbidity and mortality (M&M) conferences are standard components of medical training programs yet medical residents underutilize incident reporting systems that feed into M&M conferences. To encourage incident reporting among residents, the Department of Orthopedic Surgery at Cedars Sinai Medical Center launched a web-based, real-time complication reporting platform to capture complications.

Medication administration errors are a common source of patient harm. Developed at Cincinnati Children’s Hospital Medical Center (CCHMC), MED.Safe is an automated software package designed to monitor high-risk intravenous (IV) medications in neonatal intensive care units (NICUs) and identify medication administration discrepancies.

Shervani S, Madden W, Gleason LJ. JAMA Intern Med. 2021;181(10):1383-1384.
Prior research has found that electronic health record systems (EHRs) cannot effectively communicate medication discontinuation instructions to pharmacies. This “teachable moment” commentary highlights this issue with EHR and pharmacy system interoperability which resulted in the inadvertent dispensing of a discontinued medication. A related commentary discusses the challenges associated with attempting to discontinue prescriptions and how the CancelRx system can help mitigate these challenges.
Pilosof NP, Barrett M, Oborn E, et al. Int J Environ Res Public Health. 2021;18(16):8391.
The COVID-19 pandemic has led to dramatic changes in healthcare delivery. Based on semi-structured interviews and direct observations, researchers evaluated the impact of a new model of remote inpatient care using telemedicine technologies in response to the pandemic. Intensive care and internal medicine units were divided into contaminated and clean zones and an integrated control room with audio-visual technologies allowed for remote supervision, communication, and support. The authors conclude that this model can increase flexibility in staffing via remote consultations and allow staff to supervise and monitor more patients without compromising patient and staff safety.

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Alexander GL, Madsen RW. J Patient Saf. 2021;17(6):e483-e489.
Information technology (IT) is prevalent across healthcare settings. This study used publicly available nursing home data and a survey on IT sophistication to identify the relationship between nursing home health deficiencies and IT sophistication. Results indicate health deficiencies decreased as IT sophistication increased, suggesting investment in IT could lead to further patient safety benefits in nursing homes.
Gleason KT, Commodore-Mensah Y, Wu AW, et al. Nurse Educ Today. 2021;104:104984.
Massive online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in Healthcare MOOC was delivered in 2013 and 2014. At completion of the course, participants reported increased confidence on all six measured domains (teamwork, communication, managing risk, human environment, recognizing and responding, and culture). At 6 months post-completion, the majority agreed the content was useful and positively influenced their clinical practice, demonstrating that MOOCs are an effective interprofessional learning format.
Grundgeiger T, Hurtienne J, Happel O. Hum Factors. 2020;63(5):821-832.
The usability of information technology continues to be a challenge in health care. The authors suggest that consideration of the user is critical to improving interaction with technology and thus increasing patient safety. They provide a theoretical foundation for considering user experience in healthcare.
King CR, Abraham J, Fritz BA, et al. PLoS ONE. 2021;16(7):e0254358.
Analysis of canceled medication orders has been used to estimate medication ordering errors. Using the same dataset analyzed in their 2017 study, the authors update the analysis using machine learning to predict medication ordering errors and associated factors. Results indicate machine learning may be useful in understanding risk factors involved with medication ordering errors.
Vaghani V, Wei L, Mushtaq U, et al. J Am Med Inform Assoc. 2021;Epub Jul 20.
Based on the SaferDx and SPADE frameworks, researchers applied a symptom-disease pair-based electronic trigger (e-trigger) to identify patients hospitalized for stroke who had been previously discharged from the emergency department with a diagnosis of headache or dizziness in the preceding 30 days. Analyses show that the e-trigger identified missed diagnoses of stroke with a modest positive predictive value.
Wei W, Coffey W, Adeola M, et al. Am J Health Syst Pharm. 2021;Epub Jul 15.
Smart pumps can improve medication safety, but barriers such as workarounds and alert fatigue can limit their effectiveness. After implementing smart pumps with an electronic health record (EHR) system, this community hospital saw increased drug library compliance and fewer infusions generating alerts.