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Bergl PA, Nanchal RS, eds. Diagnostic Excellence in the ICU: Thinking Critically and Masterfully. Crit Care Clin. 2022;38(1):1-158.

Critical care diagnosis is complicated by factors such as stress, patient acuity and uncertainty. This special issue summarizes individual and process challenges to the safety of diagnosis in critical care. Articles included examine educational approaches, teamwork and rethinking care processes as improvement strategies.

A 32-year-old pregnant woman presented with prelabor rupture of membranes at 37 weeks’ gestation. During labor, the fetal heart rate dropped suddenly and the obstetric provider diagnosed umbilical cord prolapse and called for an emergency cesarean delivery. Uterine atony was noted after delivery of the placenta, which quickly responded to oxytocin bolus and uterine massage.

Bennion J, Mansell SK. Br J Hosp Med (Lond). 2021;82(8):1-8.
Many strategies have been developed to improve recognition of, and response, to clinically deteriorating patients. This review found that simulation-based educational strategies was the most effective educational method for training staff to recognize unwell patients. However, the quality of evidence was low and additional research into simulation-based education is needed.
Coldewey B, Diruf A, Röhrig R, et al. Appl Ergon. 2021;98:103544.
Medical devices without user-friendly interface designs may contribute to patient complications. This review explores problems in the use and design of mechanical ventilators that challenge safe use. The authors provide recommendations to product engineers to improve safe ventilator design.
Leibner ES, Baron EL, Shah RS, et al. J Patient Saf. 2021;Epub Sep 28.
During the first surge of the COVID-19 pandemic, a rapid redeployment of noncritical care healthcare staff was necessary to meet the unprecedented number of patients needing critical care. A New York health system developed a multidisciplinary simulation training program to prepare the redeployed staff for new roles in the intensive care unit (ICU). The training included courses on management of a patient with acute decompensation with COVID-19, critical care basics for the non-ICU provider, and manual proning of a mechanically ventilated patient.
Hennus MP, Young JQ, Hennessy M, et al. ATS Sch. 2021;2(3):397-414.
The surge of patients during the COVID-19 pandemic forced the redeployment of non-intensive care certified staff into intensive care units (ICU). This study surveyed both intensive care (IC)-certified and non-IC-certified healthcare providers who were working in ICUs at the beginning of the pandemic. Qualitative synthesis identified five themes related to supervision; quality and safety of care; collaboration, communication, and climate; recruitment, scheduling and team composition, and; organization and facilities. The authors provide recommendations for future deployments.
Finney RE, Czinski S, Fjerstad K, et al. J Pediatr Nurs. 2021;61:312-317.
The term “second victim” refers to a healthcare professional who was involved in a medical error and subsequently experiences psychological distress. An American children’s hospital implemented a peer support program for “second victims” in 2019. Healthcare providers were surveyed before and after implementation of the program with results showing the highest ranked option for support following a traumatic clinical event is peer support. Most respondents indicated they were likely to use the program if a future clinical event were to occur.

Manchester, UK: Parliamentary and Health Service Ombudsman; October 2021.

This report examines a premature infant death associated with failings of antibiotic administration, deterioration recognition and action on family concerns both during treatment and post-incident. The report issues a series of recommendations building on standard remediation guidance in the United Kingdom.
Sosa T, Sitterding M, Dewan M, et al. Pediatrics. 2021;148(4):e2020034603.
Situational awareness during critical incidents is a key attribute of effective teams. This article describes the development of a situational awareness model, which included involving families and the interdisciplinary team in huddles, a shared mental model checklist, and an electronic health record (EHR) situational awareness navigator. Use of this new model decreased emergency transfers to the ICU and improved process measures, such as improved risk recognition before medical response team activation.
Kukielka E. Patient Saf. 2021;3(3):18-27.
Trauma patients, who often suffer multiple, severe injuries and who may arrive to the Emergency Department (ED) unconscious, are vulnerable to adverse events. Using data reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers in this study evaluated the safety challenges of caring for patients presenting to the ED after a motor vehicle collision. Common challenges included issues with monitoring, treatment, evaluation, and/or documentation, patient falls, medication errors, and problems with transfers.

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.

Grailey K, Leon-Villapalos C, Murray E, et al. BMJ Open. 2021;11(8):e046699.
Psychological safety enables staff to raise concerns, reduce mistakes and learn from errors. The majority of surveyed intensive care unit staff in three units within one trust in London reported feeling psychologically safe within their teams (e.g. being able to bring up problems). In a novel finding, this study identified potential negative consequences of psychological safety, including distraction and fatigue for team leaders.
Kaya GK. Appl Ergon. 2021;94:103408.
A systems approach provides a framework to analyze errors and improve safety. This study uses the Systems Theoretic Process Analysis (STPA) to analyze risks related to pediatric sepsis treatment process. Fifty-four safety recommendations were identified, the majority of which were organizational factors (e.g., communication, organizational culture).
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.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.

Delays in treatment due to device misuse or design flaws can result in patient harm. This recall announcement highlights the omission of instructions describing a distinct device feature that, if a surgeon is unaware of it, reduces emergent umbilical vein catheter placement safety. Two deaths have been reported due to problems with the device.
Urquhart A, Yardley S, Thomas E, et al. J R Soc Med. 2021;Epub Aug 4.
This mixed-methods study analyzed patient safety incident reports between 2005-2015 to characterize the most frequently reported incidents resulting in severe harm or death in acute medical units. Of the 377 included reports, diagnostic errors, medication-related errors, and failure to monitor patient incidents were most common. Patients were at highest risk during handoffs and transitions of care. Lack of active decision-making during admission and communication failures were the most common contributors to incidents.
Marziliano A, Burns E, Chauhan L, et al. J Gerontol A Biol Sci Med Sci. 2021;Epub Jul 19.
Many COVID-19 patients present with atypical symptoms, such as delirium, smell and taste dysfunction, or cardiovascular features. Based on inpatient electronic health record data between March 1 and April 20 of 2020, this cohort study examined the frequency of atypical presentation of COVID-19 among older adults. Analyses suggest that atypical presentation was often characterized by functional decline or altered mental status.
Driessen RGH, Latten BGH, Bergmans DCJJ, et al. Virchows Arch. 2020;478(6):1173-1178.
Autopsies are an important tool for detecting misdiagnoses. Autopsies were performed on 32 septic individuals who died within 48 hours of admission to the intensive care unit. Of those, four patients were found to have class I missed major diagnosis. These results underscore the need to perform autopsies to improve diagnosis.
Diabes MA, Ervin JN, Davis BS, et al. Ann Am Thorac Soc. 2021;18(6):1027-1033.
A key feature of safety culture is the psychological safety of all staff to feel empowered to speak up about errors or mistakes. In this study of intensive care unit clinicians, job strain, leader inclusiveness and perception of teamwork were associated with psychological safety. However, psychological safety was not associated with performance of either spontaneous breathing trials or lung-protective ventilation. Future research should focus on strategies to improve psychological safety in intensive care units.