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Chen Y-F, Armoiry X, Higenbottam C, et al. BMJ Open. 2019;9:e025764.
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.
Wood C, Chaboyer W, Carr P. Int J Nurs Stud. 2019;94:166-178.
Early detection of patient deterioration remains an elusive patient safety target. This scoping review examined how nurses employ early warning scoring systems that prompt them to call rapid response teams. Investigators identified 23 studies for inclusion. Barriers to effective identification and treatment of patient deterioration included difficulty implementing early warning score systems, overreliance on numeric risk scores, and inconsistent activation of rapid response teams based on early warning score results. They recommend that nurses follow scoring algorithms that calculate risk for deterioration while supplementing risk scoring with their clinical judgment from the bedside. A WebM&M commentary highlighted how early recognition of patient deterioration requires not only medical expertise but also collaboration and communication among providers.
Smith AF, Plunkett E. Anaesthesia. 2019;74:508-517.
Health care leaders have embraced applying safety sciences methods to improve care delivery. This review discusses the evolution of health care safety from focusing on reactive analysis and response to error (Safety-1) to one that seeks to prevent errors through emphasizing safe system design (Safety-2). The authors advocate for developing a resilient system to examine what works well and incorporate those practices into daily work.
Smulyan H. Am J Med. 2019;132:153-160.
Misinterpretations of critical tests can lead to diagnostic delays and patient harm. This review suggests combining computerized and human analysis of electrocardiogram results to enhance test interpretation accuracy and effectiveness.
Sutherland A, Ashcroft DM, Phipps DL. Arch Dis Child. 2019;104:588-595.
Using clinical vignettes, investigators conducted semi-structured interviews with those prescribing medications in a pediatric intensive care unit to better understand human factors contributing to prescribing errors. They found that cognitive load was the main contributor to such errors.
Ratwani RM, Reider J, Singh H. JAMA. 2019;321:743-744.
Health information technology (IT) usability problems can affect patient safety. This commentary offers strategies to reduce the potential for unintended consequences associated with health IT. Recommendations include instituting a national registry of usability issues, establishing design standards, addressing unintended harms, simplifying documentation requirements, and developing standard measures for usability and safety.
Jones TS, Black IH, Robinson TN, et al. Anesthesiology. 2019;130:492-501.
Surgical fires, though uncommon, can result in serious harm. This review highlights three components to be managed in the operating room to prevent fires: an oxidizer, an ignition source, and a fuel. The authors provide recommendations to ensure each element is handled safely.
Carayon P, Wooldridge A, Hose B-Z, et al. Health Aff (Millwood). 2018;37:1862-1869.
System and process weaknesses can hinder safe patient care. This commentary raises awareness of human factors engineering as a key opportunity for enhancing patient safety. The authors provide recommendations to drive adoption and spread of human factors strategies through targeted education, clinician–engineer partnerships, and coordinated improvement efforts.
Ratwani RM, Savage E, Will A, et al. Health Aff (Millwood). 2018;37:1752-1759.
Although health information technology has been shown to improve patient safety, problems with implementation and user interface design persist. Unintended consequences associated with the use of electronic health record (EHR) and computerized provider order entry (CPOE) systems remain a safety concern. Pediatric patients may be particularly vulnerable to medication errors associated with EHR usability. Researchers examined 9000 safety event reports over a 5-year period from 3 pediatric health care facilities and found that 5079 events were related to the EHR and medication. Of these, 3243 identified EHR usability as contributing to the event, 609 of which reached the patient. Incorrect dosing was the most common medication error detected across the three facilities. A previous WebM&M commentary highlighted the unintended consequences of CPOE.
Powers EM, Shiffman RN, Melnick ER, et al. J Am Med Inform Assoc. 2018;25:1556-1566.
Although hard-stop alerts can improve safety, they have been shown to result in unintended consequences such as delays in care. This systematic review suggests that while implementing hard stops can lead to improved health and process outcomes, end-user involvement is essential to inform design and appropriate workflow integration.
Papadopoulos I, Koulouglioti C, Ali S. Contemp Nurse. 2018;54:425-442.
Robotics are increasingly used to assist in both complicated and routine activities in health care. Although safety hazards associated with robotic technologies have been explored in surgery, risks related to purely assistive devices is understudied. This review highlights clinician perspectives regarding assistive robots in health care and highlights infection control and reliability issues as concerns associated with their use.

Ibrahim M; Gyuchan S; Jun GT; Robinson S. Safety Sci. 2018;106:104-120.

This literature review examined the application of system dynamics, a simulation method that incorporates qualitative and quantitative data to characterize and predict how complex systems will perform over time, to patient safety. The authors applied a human factors framework to this literature and identified several influences on safety, including supervision, external factors, and organizational culture. The authors conclude that the field of system dynamics can be applied to health care in order to improve patient safety.
Simsekler MCE, Ward JR, Clarkson J. Ergonomics. 2018;61:1046-1064.
In aviation and other high reliability industries, organizations prioritize proactive risk identification in addition to root cause analysis after safety events occur. Researchers developed a risk identification framework for their health system and tested its feasibility with health care workforce members.
Joseph A, Bayramzadeh S, Zamani Z, et al. HERD. 2018;11:137-150.
Elements of the work environment can affect the safety of health care delivery. This literature review summarizes research to inform architectural and interior design improvements for operating rooms that support safety. The discussion highlights environmental themes associated with layout, acoustics, and lighting that can affect teamwork, processes, and communication in the operating room.
Alidina S, Goldhaber-Fiebert SN, Hannenberg AA, et al. Implement Sci. 2018;13:50.
Checklists have been shown to improve surgical outcomes in clinical trials, but their effectiveness in real-world settings is variable. This implementation study examined factors related to checklist use in the operating room for crises rather than routine practice. Investigators surveyed individuals who downloaded a checklist from two websites about whether they used a checklist regularly in specific clinical situations. Thorough checklist implementation, leadership support, and dedicated staff training time led to more regular use of the checklist. Conversely, frontline resistance and lack of clinical champions undermined checklist use. The authors conclude that optimizing organizational conditions should increase the use of checklists during crises in operating rooms. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.
Patterson ES. Hum Factors. 2018;60:281-292.
Poor design of health information technology can lead to miscommunication, burnout, and inappropriate documentation. This review of the literature identified three practice deviations associated with health IT, including workflow disruption, inappropriate use of text fields, and use of handwritten paper or whiteboard notes instead of health IT. The author recommends improvements focused on electronic health record display to enhance communication.
Freund Y, Goulet H, Leblanc J, et al. JAMA Intern Med. 2018;178:812-819.
In emergency departments (EDs), high medical acuity, incomplete information, and productivity pressures can contribute to preventable adverse events and near misses. Systems solutions have improved medication safety and team communication in EDs, but few interventions have meaningfully affected diagnostic and treatment errors. Investigators conducted a randomized controlled trial to evaluate the impact of ED physicians' cross-checking their diagnostic and treatment plans with another physician. Compared with standard care, patients whose physicians performed cross-checking were 40% less likely to experience a preventable adverse event or near miss. This study's design, large sample size, and ascertainment of patient-centered outcomes were particularly robust. A past WebM&M commentary and PSNet perspective examined other initiatives to improve emergency department safety.
Tolley CL, Slight SP, Husband AK, et al. Am J Health Syst Pharm. 2018;75:239-246.
This systematic review of clinical decision support for safe medication use found that such systems are incompletely implemented and lack standardization and integration of patient-specific factors. The authors suggest that reducing alert fatigue and employing human factors principles would enhance decision support effectiveness.