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Lin JS, Olutoye OO, Samora JB. J Pediatr Surg. 2022;Epub Jul 6.
Clinicians involved in adverse events may experience feelings of guilt, shame, and inadequacy; this is referred to as “second victim” phenomenon. In this study of pediatric surgeons and surgical trainees, 84% experienced a poor patient outcome. Responses to the adverse event varied by level of experience (e.g., resident, attending), gender, and age.

Rockville, MD: Agency for Healthcare Research and Quality; September 2022. AHRQ Publication No. 22-0026-3-EF.

Correct consideration of the likelihood that a patient may have a potential disease guides each level of diagnostic decision making; misjudgments can be fatal. This issue brief introduces an information-focused framework to examine how clinicians determine probability and discusses educational avenues for enhancing those skills. The publication is part of a report series on diagnostic safety.
Quesenberry M. Patient Safety. 2022;4:6-9.
Medical devices intended to improve patient safety can unintentionally lead to patient harm. This patient safety alert draws attention to the risk of injury when hospital wheelchairs are used by staff, patients, or visitors who may not have training in safe use. Understanding the proper use of the wheelchair, particularly folding wheelchairs, is crucial to ensuring safety.

NAM’s Action Collaborative on Clinician Well-Being and Resilience. Washington DC, American Association of Medical Colleges or virtual; October 3, 2022, 10:00 AM – 12:00 PM (eastern).

Concerted effort has been undertaken to understand the impact of clinician burnout on patient safety. This webinar will discuss the culmination of a six-year effort to design a national multidisciplinary guidance to address system issues that affect the wellbeing of clinicians.

This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a  peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services.

AHA Training. November 9-10, 2022. Hilton Garden Inn, Houston, TX.
This education program will present group-focused opportunities for participants to learn how to apply Agency for Healthcare Quality and Research TeamSTEPPS 2.0 curriculum methods to develop staff training and improve team communication in their organizations.

AHA Team Training. October 6 – November 17, 2022.

Despite the recognition that teamwork is essential to safe care, its implementation into established processes can be a challenge. Building on the established TeamSTEPPS® principles, this virtual workshop series focuses on leadership, change management and process integration to enrich organizational efforts to embed effective teamwork into care.
Harris CK, Chen Y, Yarsky B, et al. Acad Pathol. 2022;9:100049.
Physicians, including resident physicians, report safety events at lower rates than nurses and other staff. This study analyzed adverse event and near miss reporting by residents in one American hospital. Although pathology residents accounted for more than 5% of residents in the hospital, they only accounted for 0.5% of all reports.
Ghaith S, Campbell RL, Pollock JR, et al. Healthcare (Basel). 2022;10:1328.
Obstetric and gynecologic (OB/GYN) physicians are frequently involved in malpractice lawsuits, some of which result in catastrophic payouts. This study categorized malpractice claims involving OB/GYN trainees (students, residents, and fellows) between 1986 and 2020. Cases are categorized by type of injury, patient outcome, category of error, outcome of lawsuit, and amount of settlement.

Hospital Quality Institute. Long Beach, CA (October 3-4, 2022) and Napa, CA (November 6-7).

Zero harm is a stated goal across health care. This in-person conference will be held in two locations to bring improvement experience from the front line to regional audiences. Each event will feature a track examining health equity and implicit bias as factors in safe care provision.
Stake-Nilsson K, Almstedt M, Fransson G, et al. BMC Nurs. 2022;21:123.
Medication dose errors can lead to serious adverse events. This systematic review concluded that digital technologies – such as dosing calculators, web-based courses, simulation, and personal digital assistants – can reduce medication dosing errors among nursing students.

Farnborough, UK: Healthcare Safety Investigation Branch; July 7, 2022.

Misuse of insulin pens contributes to never events associated with diabetic medication therapy in hospitalized patients. This investigation of an injurious insulin extraction workaround culminated in recommendations to improve insulin administration safety including the explicit use of pen devices to administer U-500 insulin.
Taylor DJ, Goodwin D. J Med Ethics. 2022;Epub Jul 8.
Normalization of deviance describes a situation where individuals, teams or organizations accept a lower standard of performance until that lower standard becomes the “norm” and can threaten patient safety. This article describes five serious medical errors in obstetrics and highlights how normalization of deviance contributed to each event.
Koch A, Kozhumam A. Health Promot Pract. 2022;23:555-559.
Racial biases have been uncovered in pediatric emergency care; for example, Black children are less likely to receive pain medication for appendicitis. This article describes the use of the Racism as Root Cause (RRC) framework to identify and reduce adultification (when children are perceived or treated as being older than they are) of Black children in emergency departments. RRC calls for systemic, rather than individual, efforts.

A 49-year-old woman was referred by per primary care physician (PCP) to a gastroenterologist for recurrent bouts of abdominal pain, occasional vomiting, and diarrhea. Colonoscopy, esophagogastroduodenoscopy, and x-rays were interpreted as normal, and the patient was reassured that her symptoms should abate. The patient was seen by her PCP and visited the Emergency Department (ED) several times over the next six months. At each ED visit, the patient’s labs were normal and no imaging was performed.

Waldron J, Denisiuk M, Sharma R, et al. Injury. 2022;53:2053-2059.
Increases in clinician workload can contribute to burnout. This study explored seasonal variation in workload in an orthopedic trauma service at one Level 1 trauma center. Findings indicate that workload was highest in the summer months and correlated with resident sleepiness scores. The study team also found that patient safety events were highest during the summer, but these were not correlated with increased workload.
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.
Institute for Healthcare Improvement.
This online class prepares individuals to apply for the Institute for Healthcare Improvement patient safety certification program. The on-demand or live sessions cover key patient safety concepts to enhance participants' knowledge about safety culture, systems thinking, leadership, risk identification and analysis, information technology, and human factors. The next live session is October 27, 2022.
American Society of Health-System Pharmacists, Institute for Safe Medication Practices.
Leadership commitment to reduce medication errors can help address this safety problem. This certificate program presents key concepts that support organizational efforts to augment medication safety, including event analysis, safety culture, risk identification, and change management.
Rehder KJ, Adair KC, Eckert E, et al. J Patient Saf. 2022;Epub Aug 10.
Teamwork is an essential component of patient safety.  This cross-sectional study of 50,000 healthcare workers in four large US health systems found that the teamwork climate worsened during the COVID-19 pandemic. Survey findings indicate that healthcare facilities with worsening teamwork climate had corresponding decreases in other measured domains, including safety climate and healthcare worker well-being. The researchers suggest that healthcare organizations should proactively increase team-based training to reduce patient harm.