Wang L, Goh KH, Yeow A, et al. J Med Internet Res. 2022;24:e23355.
Alert fatigue is an increasingly recognized patient safety concern. This retrospective study examined the association between habit and dismissal of indwelling catheter alerts among physicians at one hospital in Singapore. Findings indicate that physicians dismissed 92% of all alerts and that 73% of alerts were dismissed in 3 seconds or less. The study also concluded that a physician’s prior dismissal of alerts increases the likelihood of dismissing future alerts (habitual dismissal), raising concerns that physicians may be missing important alerts.
Kwok Y-ting, Lam M-sang. BMJ Open Qual. 2022;11:e001696.
Changes in healthcare delivery and care processes as a result of the COVID-19 pandemic have increased the risk for falls. This study explored the impact of the COVID-19 pandemic and the implementation of a fall prevention program (focused on human factors and ergonomics principles) on inpatient fall rates at one hospital in Hong Kong. Findings indicate that fall rates significantly increased from pre-COVID to during the first wave of the pandemic (July-June 2020). The fall prevention program – implemented in July 2020 – led to a reduction of fall rates, but not to pre-pandemic levels.
Kakemam E, Chegini Z, Rouhi A, et al. J Nurs Manag. 2021;29:1974-1982.
Clinician burnout, characterized by emotional exhaustion, depersonalization, and decreased sense of accomplishment, can result in worse patient safety outcomes. This study explores the association of nurse burnout and self-reported occurrence of adverse events during COVID-19. Results indicate higher levels of nurse burnout were correlated with increased perception of adverse events, such as patient and family verbal abuse, medication errors, and patient and family complaints. Recommendations for decreasing burnout include access to psychosocial support and human factors approaches.
Jang S, Jeong S, Kang E, et al. Pharmacoepidemiol Drug Saf. 2020;30:17-27.
Older patients are at greater risk of experiencing adverse drug events and recent efforts have focused on avoiding prescribing high-risk medications to these patients. This study found that while implementation of a nationwide prospective drug utilization review lowered some potentially inappropriate medication prescribing among older adults in South Korea, there were no statistically significant changes in prescribing trends.
Smart pumps are considered a valuable method to improve medication safety. This study used smart pump medication logs and reporting software to identify cancelled infusions and resolutions of infusions alerts to characterize near-miss infusion pump errors. The study identified a high number of lookalike-soundalike near-miss errors. Analyses indicate that incorrect medication and wrong dose selections account for approximately 22% of all cancelled infusions.
Librov S, Shavit I. J Pain Res. 2020;13:1797-1802.
This retrospective study evaluated the impact of a pre-sedation checklist on serious adverse events among children treated with ketamine and propofol in a pediatric emergency department. There were significantly more serious adverse events recorded after the implementation of the checklist.
Parush A, Wacht O, Gomes R, et al. J Med Internet Res. 2020;22:e19947.
This study surveyed healthcare professionals in Israel and Portugal to identify key human factors that influence the use of personal protective equipment (PPE) when caring for patients with suspected or confirmed COVID-19. Respondents attributed difficulties in wearing PPE to discomfort, challenges in hearing and seeing, and doffing. Analyses also found an association between PPE discomfort and situational awareness, but this association reflected difficulties in communication (e.g., hearing and understanding speech).
Perea-Pérez B, Labajo-González E, Acosta-Gío AE, et al. J Patient Saf. 2020;16.
Based on malpractice claims data in Spain, the authors propose eleven recommendations to mitigate preventable adverse events in dentistry. These recommendations include developing a culture of safety, improving the quality of clinical records, safe prescribing practices, using checklists in oral surgical procedures, and having an action plan for life-threatening emergencies in the dental clinic.
Patients admitted to the hospital on the weekend have been shown to experience worse outcomes compared to those admitted on weekdays. This weekend effect has been observed numerous times across multiple health care settings. However, whether patient characteristics (patients admitted on the weekend may be more severely ill) or system factors (less staffing and certain services may not be available on the weekend) are primarily responsible remains debated. In this systematic review and meta-analysis including 68 studies, researchers found a pooled odds ratio for weekend mortality of 1.16. Moreover, the weekend effect in these studies was more pronounced for elective rather than unplanned admissions. They conclude that the evidence suggesting that the weekend effect reflects worse quality of care is of low quality. A past PSNet perspective discussed the significance of the weekend effect with regard to cardiology.
Patel S, Robertson B, McConachie I. Anaesthesia. 2019;74:904-914.
Medication administration mistakes can result in serious patient harm. This review explored human factors that contribute to spinal anesthesia administration errors. The authors documented organizational, supervisory, system, and individual factors that contributed to errors. They recommend strategies to prevent such incidents, including the use of double checks and improved labeling practices.
Chew KS, van Merrienboer JJG, Durning SJ. BMC Med Educ. 2019;19:18.
Metacognition is an approach to enhance diagnostic thinking. This study used focus groups to assess physicians' and medical students' impressions of a metacognitive diagnostic checklist. Participants found the checklist to be applicable and usable, and the authors conclude that it should be tested in a clinical setting.
Hsu K-Y, DeLaurentis P, Bitan Y, et al. J Patient Saf. 2019;15:e8-e14.
Smart infusion pumps store drug safety information, but this data must be periodically updated. This study demonstrated significant delays in updating the drug information for smart infusion pumps. These delays resulted in failure to alert for two high-risk medication cases, but neither case led to patient harm.
George D, Hassali MA, Hss A-S. JMIR Hum Factors. 2018;5:e12232.
This mixed-methods study examined the usability of a mobile application for reporting medication errors at a referral hospital in Malaysia. Usability improved over each of the three cycles of testing and iterative redesign, but physician and nurse testers expressed concern about whether the safety culture supported reporting.
Rahimi R, Kazemi A, Moghaddasi H, et al. Chemotherapy (Los Angel). 2018;63:162-171.
Computerized provider order entry (CPOE) is an effective tool for reducing chemotherapy medication errors. This systematic review of CPOE and clinical decision support systems for chemotherapy administration revealed a recent proliferation in the scope and complexity of both types of electronic tools. A recent WebM&M commentary examines how to prevent and respond to catastrophic chemotherapy errors.
Chen C, Kan T, Li S, et al. Am J Emerg Med. 2016;34.
Process and procedure consistency contributes to safe, highly reliable health care. This review examined the literature on the use of standard operating procedures and checklists in prehospital emergency medicine and found encouraging results on safety improvements associated with such interventions in this practice environment.
Harada S, Suzuki A, Nishida S, et al. J Eval Clin Pract. 2017;23:582-585.
Insulin is known to be a high-risk medication. This pre–post study found that introduction of a standardized sliding scale insulin order led to decreased rates of insulin prescribing errors. However, the incidence of hyperglycemia or hypoglycemia did not change. This study demonstrates how standardization can support patient safety.
Suzuki S, Chan A, Nomura H, et al. J Oncol Pract. 2017;23:18-25.
Chemotherapy is known to be a high-risk treatment that requires specific safety protocols. This study found that pharmacy checks of physician chemotherapy orders entered via computer order entry do uncover errors. The authors conclude that electronic prescribing is not sufficient to ensure safe chemotherapy prescription and recommend maintaining the role of oncology pharmacists.
Mao X, Jia P, Zhang L, et al. PLoS One. 2015;10:e0129948.
Human factors engineering has been increasingly applied in health care. This systematic review found that while human factors engineering interventions often improved health care worker outcomes and patient safety, most studies were of moderate or low quality and few considered the relevant costs of the programs.
Chaudhary N, Varma V, Kapoor S, et al. J Gastrointest Surg. 2015;19:935-42.
This randomized control trial showed reductions in complications and improved mortality with use of the WHO surgical safety checklist in India, consistent with results from earlier studies. Within the checklist group, investigators found fewer complications when the checklist was complete, compared to cases with incomplete checklists. This adds evidence to the recent studies of checklists that reflect insufficient implementation.
Limited data exists regarding how pharmacies can prevent look-alike, sound-alike medication errors. This study found that several methods of text enhancement—including boldface type and "tall man" lettering—improved the accuracy of drug identification for look-alike drugs.
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