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van Dalen ASHM, Jung JJ, Nieveen van Dijkum EJM, et al. J Patient Saf. 2022;18:617-623.
Leveraging lessons learned in aviation, patient safety researchers have begun exploring the use of medical data recorders (i.e., “black boxes”) to identify errors and threats to patient safety. This cross-sectional study found that a medical data recorder identified an average of 53 safety threats or resilience support events among 35 standard laparoscopic procedures. These events primarily involved communication failures, poor teamwork, and situational awareness failures.
Ottawa, ON: Canadian Patient Safety Institute; 2008.
This initative defines competency domains for safe health care and outlines educational practices to achieve them. The 2nd edition of the Patient Safety Competencies was released in 2020. 

A seven-year-old girl with esophageal stenosis underwent upper endoscopy with esophageal dilation under general anesthesia. During the procedure, she was fully monitored with a continuous arterial oxygen saturation probe, heart rate monitors, two-lead electrocardiography, continuous capnography, and non-invasive arterial blood pressure measurements.

A 65-year-old man with a history of type 2 diabetes mellitus, hypertension, and coronary artery disease was transferred from a Level III trauma center to a Level I trauma center with lower extremity paralysis after a ground level fall complicated by a 9-cm abdominal aortic aneurysm and cervical spinal cord injury. Post transfer, the patient was noted to have rapidly progressive ascending paralysis. Magnetic resonance imaging (MRI) revealed severe spinal stenosis involving C3-4 and post-traumatic cord edema/contusion involving C6-7.

La Regina M, Tanzini M, Venneri F, et al for the Italian Network for Health Safety. Dublin, Ireland: International Society for Quality in Health Care; 2021.

The COVID-19 pandemic is a rapidly evolving situation that requires a system orientation to diagnosis, management and post-acute care to keep clinicians, patients, families and communities safe. This set of recommendations is anchored on a human factors approach to provide overarching direction to design systems and approaches to respond to the virus. The recommendations focus on team communication and organizational culture; the diagnostic process; patient and family engagement to reduce spread; hospital, pediatric, and maternity processes and treatments; triage decision ethics; discharge communications; home isolation; psychological safety of staff and patients, and; outcome measures. An appendix covers drug interactions and adverse effects for medications used to treat this patient population. The freely-available full text document will be updated appropriately as Italy continues to respond, learn and amend its approach during the outbreak.
Britton CR, Hayman G, Stroud N. J Perioper Pract. 2021;31:44-50.
The COVID-19 pandemic has highlighted the crucial role that team and human factors play in healthcare delivery. This article describes the impact of a human factors education and training program focused on non-technical skills and teamwork (the ONSeT project) – on operating room teams during the pandemic. Results indicate that the project improved team functioning and team leader responsiveness.
Sasangohar F, Moats J, Mehta R, et al. Hum Factors. 2020;62:1061-1068.
This article discusses the role of human factors and ergonomics in disaster management and mitigating challenges associated with the COVID-19 pandemic. Key points highlighted include the use of systems approaches, improving system-wide communication and coordination, reconceptualizing expertise development, implementing agile training methods, mitigating occupational hazards, and improving procedures for disaster management tasks.

The International Society for Quality in Health Care. March - May 2020.

The COVID-19 pandemic is a worldwide crisis that requires organizations, governments, and individuals to draw from the collective experience and rapidly improve practice. This series of webinars discuss a variety of foci to share experience from the field. Topics covered include human factors engineering, clinician support, and communication.
A 54-year old women with chronic obstructive pulmonary disease was admitted for chronic respiratory failure. Due to severe hypoxemia, she was intubated, mechanically ventilated and required extracorporeal membrane oxygenation (ECMO). During the hospitalization, she developed clotting problems, which necessitated transfer to the operating room to change one of the ECMO components. On the way back to the intensive care unit, a piece of equipment became snagged on the elevator door and the system alarmed.
Haydar B, Baetzel A, Elliott A, et al. Anesth Analg. 2020;131:1135-1145.
This systematic review was undertaken to provide clear enumeration of adverse events that have occurred during intrahospital transport of critically ill children, risk factors for those events, and guidance for event prevention to clinicians who may not be fully aware of the risks of transport. The recommendations for reducing adverse events frequently given in the 40 articles that met the inclusion criteria (reflecting 4104 children transported) included: use of checklists and improved double-checks (of, e.g., equipment before transport).
Yamada NK, Catchpole K, Salas E. Semin Perinatol. 2019;43:151174.
Human factors are frequently an important contributing factor to patient safety events. This review describes the role of human factors in patient safety and presents three case studies of human factors affecting care in the NICU. A PSNet Human Factors Primer on human factors expands on these concepts.
Lavelle M, Reedy GB, Attoe C, et al. Adv Simul (Lond). 2019;4:11.
Nonclinicians such as hospital administrators or law enforcement officials frequently encounter individuals in the health care context. Researchers developed and tested an instrument to measure nonclinician professionals' interpersonal skills and decision-making in health care environments for use in simulation training. The tool was found to be reliable and valid, and the authors suggest that it could be used to enhance patient safety training for nonclinicians.
Lefebvre G, Calder LA, De Gorter R, et al. J Obstet Gynaecol Can. 2019;41:653-659.
Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. This commentary describes the importance of standardization, checklist use, auditing and feedback, peer coaching, and interdisciplinary communication as strategies to reduce risks. The discussion spotlights the need for national guidelines and definitions to reduce variation in auditing and training activities and calls for heightened engagement of health care professionals to improve the safety and quality of obstetric care in Canada. An Annual Perspective reviewed work on improving maternal safety.
Crandell BC, Bates JS, Grgic T. J Oncol Pharm Pract. 2018;24:609-616.
Chemotherapy orders contain many steps that pose opportunities for prescribing errors. This commentary describes a six-step checklist designed to improve the reliability of the chemotherapy order review that was used by oncology pharmacists. The authors see future applications of the checklist as a cross-training and educational cognitive aid for practitioners and students.
Following surgery under general anesthesia, a boy was extubated and brought to postanesthesia care unit (PACU). Due to the patient's age and length of the surgery, the PACU anesthesiologist ordered continuous pulse-oximetry monitoring for 24 hours. Deemed stable to leave the PACU, the boy was transported to the regular floor. When the nurse went to place the patient on pulse oximetry, she realized he was markedly hypoxic. She administered oxygen by face mask, but he became bradycardic and hypotensive and a code blue was called.

Shah RK, ed. Otolaryngol Clin North Am. 2019;52:1-194.

Articles in this special issue apply safety concepts to reducing preventable patient harm in otolaryngology. The reviews highlight systems science, collaboration, leadership models, and patient experience as important to moving safety innovation forward in this specialty.
Link T. AORN J. 2018;108:165-177.
Although team development has received increased attention in health care, miscommunications that affect patient safety continue to occur. This commentary reviews factors that contribute to poor communication behaviors among perioperative nurses and summarizes guidance on how to improve team communication, such as use of standardized checklists and briefings.
A woman developed sudden nausea and abdominal distension after undergoing inferior mesenteric artery stenting. The overnight intern forgot to follow up on her abdominal radiograph, which resulted in a critical delay in diagnosing acute mesenteric artery dissection and bowel infarction.