Incomplete or delayed communication of imaging results can result in harm to the patient and have legal ramifications for the providers involved. This commentary presents a closed-loop communication model for the ordering clinician and radiologist. The model suggests the ordering clinician categorize the radiology report as “concordant” or “discordant”, and if discordant, provide an explanation.
Upadhyay S, Opoku-Agyeman W, Choi S, et al. J Public Health Manag Pract. 2022;28:505-512.
Patient engagement is a key element of successful patient safety improvement efforts, including those leveraging health information technology (IT) approaches. This longitudinal study using a national sample of hospitalizations identified a significant association between patient engagement and electronic health record (EHR) adoption with the incidence of adverse events.
Redley B, Douglas T, Hoon L, et al. J Adv Nurs. 2022;Epub Jul 7.
Frontline care providers such as nurses play an important role in reducing preventable harm. This study used qualitative methods (direct observation and participatory workshops) to explore nurses’ experiences implementing harm prevention practices when admitting an older adult to the hospital. Researchers identified barriers (e.g., lack of resources, information gaps) and enablers (e.g., teamwork, reminders) to harm prevention during the admission process.
Fear of criminal liability may inhibit clinicians from reporting medical errors, thereby reducing opportunities for learning. This commentary discusses recent legal actions brought against clinicians, including Tennessee nurse RaDonda Vaught, and the negative impact such actions may have on the longstanding disclosure movement.
Unintentionally retained foreign objects can be exacerbated by fatigue, distractions, and communication errors. This article highlights the importance of effective teamwork, high reliability orientation, and standardized surgical count methods to minimize the persistent problem of retained surgical items.
Abildgren L, Lebahn-Hadidi M, Mogensen CB, et al. Adv Simul (Lond). 2022;7:12.
Simulation is becoming more common in healthcare education programs, but often focuses on in-hospital, skills-based training aimed at developing team human factors skills. This systematic review included 72 studies from 2004-2021 that included human factors skills with a variety of different designs, types of training interventions, and assessment tools and methods. The authors concluded that simulation-based training was effective in training teams in human factors skills; additional work is needed on the retention and transfer of those skills to practice.
Zimolzak AJ, Singh H, Murphy DR, et al. BMJ Health Care Inform. 2022;29(1):e100565.
Patient safety algorithms developed through research must also be implemented into clinical practice. This article describes the process of translating an electronic health record-based algorithm for detecting missed follow-up of colorectal or lung cancer testing, from research into practice. All 12 test sites were able to successfully implement the trigger and identify appropriate cases.
Strong patient safety culture is a cornerstone to sustained safety improvements. This cross-sectional study explored nurses’ perceptions about patient safety culture. Identified areas of strength included non-punitive responses to errors and teamwork, and areas for improvement focused on supervisor and manager expectations, responses, and actions to promote safety and open communication. The authors highlight the importance of measuring patient safety culture in order to improve hospitals’ patient safety improvement practices, overall performance and quality of healthcare delivery.
Electronic health record (EHR) system implementation should optimize interoperability and support clinician decision making. This commentary discusses a strategy to aid in the sociotechnical design of interfaces and involvement of the myriad of individuals that use EHRs, including patients.
Minyé HM, Benjamin EM. Br Dent J. 2022;232:879-885.
High reliability organization (HRO) principles used in other high-risk industries (such as aviation) can be applied patient safety. This article provides an overview of how HRO principles (preoccupation with failure, situational awareness, reluctance to simplify, deference to expertise, and commitment to resilience) can be successfully applied in dentistry.
De Micco F, Fineschi V, Banfi G, et al. Front Med (Lausanne). 2022;9:901788.
The COVID-19 pandemic led to a significant increase in the use of telehealth. This article summarizes several challenges that need to be addressed (e.g., human factors, provider-patient relationships, structural, and technological factors) in order to support continuous improvement in the safety of health care delivered via telemedicine.
Wang M, Banda B, Rodwin BA, et al. J Patient Saf. 2022;Epub May 16.
Prior studies have examined students’ ability to recognize safety hazards in patient rooms using simulation; however, most of these studies focus on a single type of healthcare provider (e.g., medical or nursing students). This study compared physicians, nurses, and other healthcare workers and found that nurses identified more hazards than other providers. All healthcare workers were challenged to identify hazards of omission and those requiring two-step thinking.
Wolf L, Gorman K, Clark J, et al. J Patient Saf. 2022;Epub May 25.
Human factors play an important role in contributing to and preventing adverse events. This study found that integrating human factors into a new root cause analysis process led to an increase in the number of strong interventions implemented after adverse events.
McInerney C, Benn J, Dowding D, et al. Stud Health Technol Inform. 2022;290:364-368.
Digital health tools are increasingly used across all areas of the healthcare system. In this study, researchers convened an interdisciplinary expert panel to identify patient safety concerns associated with emerging digital health technologies and to outline recommendations to address these concerns.
Xiao Y, Smith A, Abebe E, et al. J Patient Saf. 2022;Epub May 22.
Older adults are particularly vulnerable to medication errors due to polypharmacy and medical complexities. In this qualitative study, healthcare professionals outlined several multifactorial hazards for medication-related harm during care transitions, including complex dosing, knowledge gaps, errors in discharge medications and gaps in access to care.
Atkinson MK, Benneyan JC, Bambury EA, et al. Health Care Manage Rev. 2022;47:E50-E61.
Patient safety learning laboratories (PSLL) encourage a cross-disciplinary, collaborative approach to problem solving. This study reports on how a learning ecosystem supported the success of three distinct PSLLs. Qualitative and quantitative results reveal four types of alignment and supporting practices that contribute to the success of the learning laboratories.
Gupta K, Szymonifka J, Rivadeneira NA, et al. Jt Comm J Qual Patient Saf. 2022;Epub May 28.
Analysis of closed malpractice claims can be used to identify potential safety hazards in a variety of clinical settings. This analysis of closed emergency department malpractice claims indicates that diagnostic errors dominate, and clinical judgment and documentation categories continue to be associated with a higher likelihood of payout. Subcategories and contributing factors are also discussed.
Rydenfält C. J Patient Saf Risk Manag. 2022;27:124-128.
Certain processes and routines, such as checklists, are widely used in healthcare settings to improve patient safety. In this article, the author describes two proposed approaches for the study of healthcare safety routines using human factors and a safety-II perspective.
Madigan C, Way KA, Johnstone K, et al. J Safety Res. 2022;81:203-215.
Leadership engagement in safety is essential to implementing sustainable change. This qualitative study found that rational persuasion and legitimating were the most frequently used and certain factors – such as organizational culture, safety beliefs, and leadership style – can impact how safety professionals influence managers making safety decisions in healthcare settings. The authors discuss the importance of both technical and non-technical skills to enhance influence among safety professionals.
Gong Y. Stud Health Technol Inform. 2022;291:133-150.
Reporting incidents and errors is a cornerstone of patient safety improvement efforts, but challenges remain, including low quality of reports and low rates of reporting. This article discusses the technological challenges of incident reporting and offers recommendations to improve usability in future reporting systems.
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