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Paterson EP, Manning KB, Schmidt MD, et al. J Emerg Nurs. 2022;48:319-327.
Automated dispensing cabinets (ADCs) can reduce medication dispensing errors by requiring pharmacist verification. This study found that medication overrides (i.e., bypassing pharmacist review before administration) in one pediatric emergency department were frequently not due to an emergent situation requiring immediate medication administration and could have been avoided.
Baartmans MC, Hooftman J, Zwaan L, et al. J Patient Saf. 2022;Epub Apr 21.
Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.
Hansen M, Harrod T, Bahr N, et al. Acad Med. 2022;97:696-703.
Strong physician leadership during clinical crisis can help improve patient outcomes. In this randomized controlled trial, obstetrics-gynecology and emergency medicine residents participated in one of three study arms using high-fidelity mannequins. One study arm received a bespoke leadership curriculum, one received a modified version TeamSTEPPS curriculum, and the third received no leadership training. Participants in both curriculum arms improved leadership scores from “average” before the training to “good” following the training and continuing to six months. The control arm remained unchanged at “average” before and after.

Jagsi R, Griffith KA, Vicini F, et al for the Michigan Radiation Oncology Quality Consortium. JAMA OncolEpub 2022 Apr 21. 

Concordance of patient-reported symptoms and provider-documented symptoms is necessary for appropriate patient care and has clinical implications for research. This study compared patient-reported symptoms (pain, pruritus, edema, and fatigue) following radiotherapy for breast cancer with provider assessments. Underrecognition of at least one symptom occurred in more than 50% of patients. Underrecognition was more common in Black patients and those seen by male physicians. The authors suggest that interventions to improve communication between providers and patients may not only improve outcomes but also reduce racial disparities.
Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.
Lederman J, Lindström V, Elmqvist C, et al. BMC Emerg Med. 2021;21:154.
Patients who are treated by emergency medical services (EMS) personnel but not transported to the hospital are referred to as non-conveyed patients. In this retrospective cohort study, researchers found that older adult patients in Sweden are at an increased risk of adverse events (such as infection, hospitalization, or death) within 7-days following non-conveyance.
Groves PS, Bunch JL, Sabin JA. J Clin Nurs. 2021;30:3385-3397.
While many studies have been conducted on implicit bias in healthcare, a gap exists in nurse-specific bias and impact on disparities. This scoping review identified 215 research reports on nurse bias and/or care disparities. Most were descriptive in nature and only 12 included evaluating an intervention designed to reduce nurse-related bias. Recommendations for future research include development and testing of interventions designed to reduce nurse-related bias.
Khidir H, McWilliams JM, O’Malley AJ, et al. JAMA Netw Open. 2021;4:e2125193.
While racial, ethnic, and gender biases have been widely documented at the system level, it has not been well documented at the individual physician level. This analysis of 4.5 million emergency department visits in the US showed variation in hospital admission rates among physicians, but an individual physician’s propensity to admit patients did not vary by patient sociodemographic group.

Kahneman D, Sibony O, Sunstein CR. London, UK: William Collins; 2021. ISBN 9780008472566.

Lack of agreement, or noise, in leadership and clinical decision making can contribute to poor care. This book discusses influences on human judgement that contribute to disagreement when different people receive the same information and how to prevent its negative impact. It describes the influence of noise in a variety of sectors including medicine with specific emphasis on diagnosis.
Trockel MT, Menon NK, Rowe SG, et al. JAMA Netw Open. 2020;3:e2028111.
Fatigue among health care workers can increase the risk of errors. This large cross-sectional study of attending and house staff physicians found that sleep-related impairment was associated with increased burnout, decreased professional fulfillment, and increased self-reported clinically significant medical error. Organizational policies should focus on reducing sleep-related impairment in order to reduce harm to patients and physicians.
Keller S, Yule S, Zagarese V, et al. BMJ Open. 2020;10:e035471.
Unprofessional behavior can hinder patient safety and create a disruptive work environment. Encompassing both qualitative and quantitative literature, this systematic review explored predictors and triggers of incivility in medical teams (defined as disrespectful behaviors but whose intent to harm is ambiguous). The review identified a wide range of triggers of incivility. Studies generally found that incivility occurs mainly within professional disciplines rather than across disciplines (e.g., physician to nurse) and surgery was the most commonly cited uncivil specialty. Situational and cultural triggers for incivility included excessive workload, communication issues, patient safety concerns, lack or support, and poor leadership.
Härkänen M, Turunen H, Vehviläinen-Julkunen K. J Patient Saf. 2020;16.
This study compared medication errors detected using incident reports, the Global Trigger Tool method, and direct observations of patient records. Incident reports and the Global Trigger Tool more commonly identified medication errors likely to cause harm. Omission errors were commonly identified by all three methods, but identification of other errors varied. For example, incident reports most commonly identified wrong dose and wrong time errors. The contributing factors also varied by method, but in general, communication issues and human factors were the most common contributors.
Arnetz JE, Neufcourt L, Sudan S, et al. J Nurs Care Qual. 2020;35:206-212.
Based on survey responses from nurses at one large US hospital, this study examined the association between nurse-reported bullying and nurse-sensitive patient outcomes (patient falls, central-line-associated blood stream infections, catheter-associated urinary tract infections, hospital-acquired pressure ulcers, and ventilator-associated events). The researchers found that nurse-reported bullying was significantly associated with the incidence of central-line-associated blood stream infections. Addressing nurse bullying at work may reduce certain adverse events.
Fernholm R, Holzmann MJ, Wachtler C, et al. BMC Fam Pract. 2020;21.
Much of the evidence about preventable harm in patients with psychiatric illnesses is limited to inpatient psychiatric facilities. This case-control study explores patient-related factors that place patients at an increased risk for patient safety incidents in primary or emergency care. While differences in income, education, and foreign background had some association with preventable harm, researchers found that psychiatric illness nearly doubled the risk of preventable harm among both emergency and primary care patients, with nearly half (46%) of harm attributable to diagnostic errors.

Chuck E, Assefa H. NBC News. February 8, 2020.

Maternal morbidity and perinatal harm can be exacerbated due to implicit bias. This story discusses a case of an American Indian/Alaska Native mother and infants whose deaths may have been preventable had her concerns been more effectively addressed. The situation illustrates conditions in the broader indigenous peoples’ community that indicate a lack of respect and patient-centeredness as factors contributing to poor care.
Russ AL, Militello LG, Glassman PA, et al. J Patient Saf. 2019;15:191-197.
Cognitive task analysis is a human factors engineering method used to evaluate individuals' thinking to better understand safety. This study examined medication safety through the lens of cognitive task analysis and concluded that the method identifies actionable safety gaps and should be more widely used in health care.
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.