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ISMP Medication Safety Alert! Acute care edition.  September 9, 2021;26(18);1-5.

Disrespectful behavior is a persistent contributor to failures in medical care. This article summarizes influences that enable the acceptance and perpetuation of unprofessional behaviors and calls for data to assess its presence and impact in health care environments. The deadline for survey participation is November 19, 2021.
Sosa T, Sitterding M, Dewan M, et al. Pediatrics. 2021;148(4):e2020034603.
Situational awareness during critical incidents is a key attribute of effective teams. This article describes the development of a situational awareness model, which included involving families and the interdisciplinary team in huddles, a shared mental model checklist, and an electronic health record (EHR) situational awareness navigator. Use of this new model decreased emergency transfers to the ICU and improved process measures, such as improved risk recognition before medical response team activation.
Lamming L, Montague J, Crosswaite K, et al. BMC Health Serv Res. 2021;21(1):1038.
Patient safety huddles are used to promote team communication about safety threats. Based on direct observations and a survey of teamwork and safety climate, researchers concluded that patient safety huddles across three National Health Service (NHS) trusts improved teamwork and safety culture, especially for nurses.
Shea T, De Cieri H, Vu T, et al. Safety Sci. 2021;143:105413.
Assessing safety climate is critical to understanding how organizational efforts can improve safety. This review identified deficiencies and inconsistencies in the way that safety climate has been conceptualized and measured. The authors underscore the importance of a consistent approach to measuring safety climate in order to evaluate its impact on patient safety outcomes.

ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares reported vaccine errors and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.
Aasen L, Johannessen A‐K, Ruud Knutsen I, et al. J Clin Nurs. 2021;Epub Sep 28.
Patients receiving hospital-level care at home (hospital-at-home, (HAH) have fewer complications, better patient and family satisfaction, and better outcomes. This study describes nurses’ and physicians’ perspectives of pediatric HAH. Three themes evolved: building a trusting relationship with the child and family; performing essential skills; and acting as the “hub” between families and providers.
Abraham P, Augey L, Duclos A, et al. J Patient Saf. 2021;17(7):e615-e621.
Patient misidentification errors are common and potentially catastrophic. Patient identification incidents reported in one hospital were examined to identify errors and contributory factors. Of the 293 reported incidents, the most common errors were missing wristbands, wrong charts or notes in files, administrative issues, and wrong labeling. The most frequent contributory factors include absence of patient identity control, patient transfer, and emergency context.
Cecil E, Bottle A, Majeed A, et al. Br J Gen Pract. 2021;71(708):e547-e554.
There has been an increased focus on patient safety, including missed diagnosis, in primary care in recent years. This cohort study evaluated the incidence of emergency hospital admission within 3 days of a visit with a GP with missed sepsis, ectopic pregnancy, urinary tract infection or pulmonary embolism. Shorter duration of appointment and telephone appointment (compared with in person) were associated with increased incidence of self-referred emergency hospital admission.

American College of Emergency Physicians, National Association of Emergency Medical ServicesAnn Emerg Med. 2021;78(3):e37-e57. 

Emergency medical services (EMS) are often provided in stressful situations that require an orientation to safety to keep patients and staff from harm. This policy statement outlines components of an EMS safety orientation that rests on an established culture of safety in the field.
Zaheer S, Ginsburg LR, Wong HJ, et al. BMC Nurs. 2021;20(1):134.
A culture of safety is essential to reducing medical errors and improving patient safety. In this mixed-methods study, researchers found that acute care nurses’ perceptions of senior leadership, teamwork, and turnover intention were associated with perceived patient safety.

Collaborative for Accountability and Improvement. October 21, 2021. 2:00–3:00 PM (eastern).

Communication-and-resolution program (CRP) initiatives are a valuable strategy for improving support and transparency after an adverse incident. This webinar will discuss how patients and families feel about support mechanisms after they have experienced medical error, if they were involved in a CRP process and the types of information they require after a harmful incident.
Berdot S, Vilfaillot A, Bézie Y, et al. BMC Nurs. 2021;20(1):153.
Interruptions have been identified as a common source of medication errors. In this study of the effectiveness of a “do not interrupt” vest worn by nurses from medication preparation to administration, neither medication administration error or interruption rates improved.

Zirger JM, Centers for Disease Control and Prevention. Fed Register. September 27, 2021;86:53309-53312.

Tracking healthcare-associated infection (HAI) data aids in national, regional, and organizational design of HAI improvement efforts. This notice calls for public comment on the continuation of the National Healthcare Safety Network HAI information collection process. The comment period closes November 26, 2021.
Huynh I, Rajendran T. BMJ Open Qual. 2021;10(3):e001363.
Unintentional therapeutic duplication can lead to life-threatening complications. As part of a quality improvement project on a surgical ward, staff were educated about the risks of therapeutic duplication and strategies to decrease it. After one month of education and reminders, the rate of therapeutic duplication decreased by more than half.
Volkar JK, Phrampus P, English D, et al. J Patient Saf. 2021;17(7):e689-e693.
The goal of peer review is to provide clinicians with the opportunity to learn from errors. A multidisciplinary panel at one academic medical center established a new approach for physician peer review which incorporated a protected electronic portal for communication and engagement and a Just Culture peer review algorithm to identify opportunities for system improvements. The new approach decreased the average time necessary for full case review and increased provider engagement.
Winters BD, Slota JM, Bilimoria KY. JAMA. 2021;326(12):1207.
Alarm fatigue is a pervasive contributor to distractions and error. This discussion examines how, while minimizing nuisance alarms is important, those efforts need to be accompanied by safety culture enhancements to realize lasting progress toward alarm reduction.
Slikkerveer M, van de Plas A, Driessen JHM, et al. J Patient Saf. 2021;17(7):e587-e592.
Anticoagulants, such as low-molecular-weight heparin (LMWH), are known to be high-risk for adverse drug events. This cross-sectional study identified prescribing errors – primarily lack of dosage adjustment for body weight and/or renal function – among one-third of LMWH users admitted to one hospital over a five-month period.
Hendrickx I, Voets T, van Dyk P, et al. J Med Internet Res. 2021;23(7):e19064.
Prioritization of patient complaints allows inspectors to follow up more quickly on those that pose the most severe safety risk. Using text mining and sentiment analysis, more than 22,000 patient complaints were assigned a severity category. The ‘bag-of-words representation’ was most successful for severity predicting and could be used to triage patient complaints.
Taylor E, Hignett S. Int J Environ Res Public Health. 2021;18(15):7780.
Informed environmental features, such as the built environment, can improve safety outcomes. The authors propose a theoretic model and matrix (DEEP SCOPE; DEsigning with Ergonomic Principles – Safety as Complexity of the Organization, People, and Environment) intended to synthesize design interventions into a systems-based model using the principles of human factors and ergonomics.
Ceschi A, Noseda R, Pironi M, et al. JAMA Netw Open. 2021;4(9):e2124672.
Medication reconciliation at hospital discharge can result in reduction of adverse events when the patient returns to the community. This study measured the effect of medication reconciliation performed at admission to hospital on subsequent health care outcomes. For patients ages 85 years and older, taking more than 10 medications at hospital admission, or both, medication reconciliation at admission did not have an impact on 30-day readmission to hospital.