Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, et al. J Patient Saf. 2021;17:e20-e27.
Patient safety in primary care is an emerging focus. This cross-sectional study across primary care clinics in England explored the main factors contributing to patient-reported harm experiences. Factors included incidents related to communication, care coordination, and incorrect or delayed; diagnosis and/or treatment.
Foster CB, Ackerman K, Hupertz V, et al. Pediatrics. 2020;146:e20192057.
This article describes the implementation and results of catheter-associated urinary tract infection (CAUTI) prevention efforts by a large network of children’s hospitals between 2011 and 2017. Prevention efforts included catheter insertion and maintenance bundles. After implementation of the bundles, CAUTI rates across the network decreased by 61.6%.
Griffey RT, Schneider RM, Todorov AA. Ann Emerg Med. 2020;76:230-240.
This study assessed the performance of an automated emergency department (ED) trigger tool designed to identify a more efficient sample of adverse event cases for chart review. Beginning with a set of 97 candidate triggers, researchers identified those triggers associated with adverse events and arrived at a narrowed set of 30 triggers, eliminating almost half of the population of records eligible for manual review. This computerized query may eliminate the need for manual screening for triggers.
White AA, Sage WM, Mazor KM, et al. Jt Comm J Qual Patient Saf. 2020;46:591-595.
This commentary discusses safety outcomes associated with late career practitioners, measuring practitioner performance, and options for practitioners with declining performance, including key features and lessons learned from early adopters of late career practitioner programs.
DiSilvio B, Virani A, Patel S, et al. Crit Care Nurs Q. 2020;43:413-427.
This article discusses several aspects essential to surge planning and preparing for the COVID-19 pandemic, including surge planning, limiting health care worker exposure, logistics for medication delivery, delivering emergent care in patients with COVID-19, and safe practices for patient transport.
This study reviewed adverse event reporting forms from 16 dental schools and found that the forms were not standardized in structure, organization, or content. Adoption of a standardized method for event collection and assessment would allow for quality improvement and increase patient safety.
Maurer NR, Hogan TH, Walker DM. Med Care Res Rev. 2021;78:643-659.
This systematic review examined effectiveness of hospital- or system-wide interventions in reducing healthcare-associated infections (HAIs). The review identified several strategies for reducing HAIs, including enhanced environmental cleaning using disinfection technologies; EHR implementation; multimodal infection control programs; multichannel hand hygiene promotion; and hospital-wide cultural transformations. The review identifies approaches meriting additional research and exploration.
Decesare JZ, Bush SY, Morton AN. J Patient Saf. 2020;16:e179-e181.
This article reports on the impact of an OB hospitalist program on serious safety events in one hospital over a two-year period. After program implementation, there was a significant reduction in serious safety events.
McGarry BE, Grabowski DC, Barnett ML. Health Aff (Milwood). 2020;39:1812-1821.
Based on data from the CMS COVID-19 Nursing Home Database, this study found that more than 20% of nursing homes report a severe shortage of personal protective equipment (PPE) and shortage of staff; rates for staffing and PPE did not improve from May to July of 2020. Nursing homes with COVID-19 cases among residents and staff, and those with lower quality scores, were more likely to report shortages.
Inappropriate care activities can cascade to significantly impact patient safety. This article shares how medication side effects can be misdiagnosed to perpetuate harm in older patients rather than getting to the root of the care concerns.
This article describes an innovative expert consensus process to generate a contemporary list of chart-review based triggers and adverse event measures for assessing the incidence of inpatient and outpatient adverse events. A panel of 71 experts from nine institutions identified 218 triggers and measures with high or very high clinical importance deemed suitable for chart review and 198 were found suitable for electronic surveillance; 192 items were suitable for both.
This study examined variation in operative technical skills among patients undergoing colorectal and non-colorectal procedures and the association with patient outcomes. Higher technical skills were significantly associated with lower rates of complications, unplanned reoperations, and death or serious morbidity. The findings suggest that this skill variation accounts for more than 25% of the variation in patient outcomes.
Musunur S, Waineo E, Walton E, et al. Acad Psychiatry. 2020;44:586-591.
This article describes the impact of an interactive session with second-year medical students utilizing case-based learning, small group discussion, and video vignettes intended to prepare healthcare providers to anticipate and understand the impact of medical errors. Pre- and post-surveys found that this one-hour, small-group session increased medical students’ understanding of the impact of medical errors and adverse events and the resources available to support providers.
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