Gregory H, Cantley M, Calhoun C, et al. Am J Emerg Med. 2021;46:266-270.
Medication safety continues to be a challenge in most healthcare settings, including emergency departments. In this academic emergency department, an overall error rate of 16.5% was observed, including errors in directions, quantity prescribed, and prescriptions written with refills. Involving a pharmacist at discharge may increase patient safety.
Liukka M, Hupli M, Turunen H. Leadersh Health Serv (Bradf Engl). 2021;Epub Sep 8.
The Hospital Survey on Patient Safety Culture and Nursing Home Survey on Patient Safety Culture were used in one Finish healthcare organization to assess 1) differences in employee perceptions of safety culture in their respective settings, and 2) differences between professionals’ and managers’ views. Managers assessed safety culture higher than professionals in both settings. Acute care patient safety scores were significantly positive in 8 out of twelve domains, compared to only one in long-term care.
Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. Infect Control Hosp Epidemiol. 2021;Epub Sept 13.
Using data reported to the National Healthcare Safety Network, this study identified significant increases in the incidence of healthcare-associated infections from 2019 to 2020. The authors conclude that these findings suggest a need to return to conventional infection control and prevention practices and prepare for future pandemics.
Diagnostic error reduction continues to be a patient safety focus. This article outlines innovative ways clinical laboratory professionals can support diagnostic excellence, such as improved communication between laboratory professionals, providers and patients.
Barber Doucet H, Ward VL, Johnson TJ, et al. Clin Pediatr (Phila). 2021;60(9-10):408-417.
Healthcare provider implicit biases can lead to inequitable care delivery and poorer patient outcomes. Pediatric residents were surveyed about their attitudes, skill level, and preferred educational interventions related to implicit bias and care of diverse populations. Prior medical education or training in diversity and bias-related skills was associated with higher self-reported skill level.
Sidi A, Gravenstein N, Vasilopoulos T, et al. J Patient Saf. 2021;17(6):e490-e496.
Nontechnical skills, such as teamwork and communication, can influence performance in technical fields like surgery or emergency medicine. This study found that simulation-based assessments can measure improvements in nontechnical skills and cognitive performance among residents.
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.
Warm EJ, Ahmad Y, Kinnear B, et al. Acad Med. 2021;96(9):1268-1275.
Technical and procedural skills are an important emphasis of medical training. This article briefly summarizes the “as low as reasonably achievable” (ALARA) approach, which was developed for the nuclear industry and has been used in radiology. The authors outline how ALARA risk standards can be adapted by training program directors to measure procedural competency and assess and reduce bedside procedural risks.
Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478(6):1179-1185.
Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.
Combs CA, Einerson BD, Toner LE. Am J Obstet Gynecol. 2021;Epub Jul 30.
Maternal and newborn safety is challenged during cesarean delivery due to the complexities of the practice. This guideline recommends specific checklist elements to direct coordination and communication between the two teams engaged in cesarean deliveries. The guideline provides a sample checklist and steps for its implementation.
Boquet A, Cohen T, Diljohn F, et al. J Patient Saf. 2021;17(6):e534-e539.
This study classified flow disruptions affecting the anesthesia team during cardiothoracic surgeries. Disruptions were classified into one of six human factors categories: communication, coordination, equipment issues, interruptions, layout, and usability. Interruptions accounted for nearly 40% of disruptions (e.g., events related to alerts, distractions, searching activity, spilling/dropping, teaching moment).
Van Slambrouck L, Verschueren R, Seys D, et al. J Prof Nurs. 2021;37(4):765-770.
An online survey of nursing students in Belgium found that about one in three students were involved in a patient safety incident during their clinical training, and the majority experienced emotional distress after the event. Medical and nursing curriculum should include opportunities for competency development to support peers involved in patient safety incidents.
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).
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.
D'Angelo JD, Lund S, Busch RA, et al. Surgery. 2021;170(2):440-445.
This study evaluated the type and effectiveness of resident and faculty coping strategies following an intraoperative error and the interaction with physician gender. Results show that while men and women surgeons experience adverse events at approximately the same rate, the coping methods utilized and effectiveness of the methods varied.
Wang X, Wilson C, Holmes K. J Gerontol Soc Work. 2021:1-17.
Nursing home residents are especially vulnerable to COVID-19 due to their age and communal living conditions. Using publicly available data for nursing homes in Florida, this study explored the association between nursing home characteristics and COVID-19 cases and deaths. Findings suggest that the likelihood of COVID-19 cases in nursing homes is related to ownership status, facility size and average occupancy rate, rather than quality (as measured by infection prevention and control deficiencies).
Medication errors are common in pediatric patients who require care from emergency medical services. This randomized trial measured the impact of a mobile app in reducing medication errors during simulated pediatric out-of-hospital cardiac arrest scenarios. Advanced paramedics were exposed to a standardized video simulation of an 18-month of child with cardiac arrest and tested on sequential preparations of intravenous emergency drugs of varying degrees of difficulty with or without mobile app support. Compared with conventional drug preparation methods, use of the mobile app significantly decreased the rate of medication errors and time to drug delivery.
Burrus S, Hall M, Tooley E, et al. Pediatrics. 2021;148(3):e2020030346.
Based on analysis of four years of data submitted to the Child Health Patient Safety Organization (CHILDPSO), researchers sought to identify types of serious safety events and contributing factors. Three main groups of serious safety events were identified: patient care management, procedural errors, and product or device errors. Contributing factors included lack of situational awareness, process failures, and failure to communicate effectively.
Davidson JE, Chechel L, Chavez J, et al. Am J Crit Care. 2021;30(5):375-384.
Nurses play a critical role in ensuring patient safety. Following the Joint Commission’s revised standards for titration of continuous intravenous medications, 730 nurses were surveyed about their experiences. Based on 159 comments, two overarching themes were identified: harms (e.g., erosion of workplace wellness, moral dilemma, patient safety) and professionalism (e.g., autonomy, nurse proficiency).
Prior research found significant confusion among physicians in understanding Physician Orders for Life-Sustaining Treatment (POLST) documents, which can lead to errors. This study found that emergency medical services (EMS) personnel did not exhibit adequate understanding of all POLST or living will documents either. The researchers propose that patient video messaging can increase clarity about treatment, and preserve patient safety and autonomy.
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