Ong N, Mimmo L, Barnett D, et al. Dev Med Child Neurol. 2022;Epub May 16.
Patients with intellectual disabilities may be at higher risk for patient safety events. In this study, researchers qualitatively analyzed hospital incident reporting data and identified incidents categories disproportionately experienced by children with intellectual disabilities. These incident categories included medication-intravenous fluid issues, communication failures, clinical deterioration, and care issues identified by parents.
Joseph K, Newman B, Manias E, et al. Patient Educ Couns. 2022;Epub Apr 26.
Lack of patient engagement in care can place them at increased risk for safety events. This qualitative study explored ethnic minority stakeholder perspectives about patient engagement in cancer care. Focus groups consisting of participants from consumer and health organizations involved in cancer care in Australia identified three themes supporting successful engagement – consideration of sociocultural beliefs about cancer, adaptation of existing techniques tailored to stakeholders (e.g., culturally specific content), and accounting for factors such as cultural competence during implementation.
Buhlmann M, Ewens B, Rashidi A. J Adv Nurs. 2022;Epub Apr 22.
The term “second victims” describes clinicians who experience emotional or physical distress following involvement in an adverse event. Nurses and midwives were interviewed about “moving on” from the impact of a critical incident. Five main themes were identified: Initial emotional and physical response, the aftermath, long-lasting repercussions, workplace support, and moving on. Lack of organizational support exacerbated the nurses’ and midwives’ responses.
Carfora L, Foley CM, Hagi-Diakou P, et al. PLoS ONE. 2022;17:e0267030.
Patients are frequently asked to complete patient-reported outcome measures (PROM), or standardized questionnaires, to assess general quality of life, screen for specific conditions or risk factors, and perspectives on their health. This review identified 14 studies related to patient perspectives regarding PROMs. Three themes emerged: patient preferences regarding PROMs, patient perceived benefits, and barriers to patient engagement with PROMs.
Redley B, Taylor N, Hutchinson AM. J Adv Nurs. 2022;Epub Apr 22.
Nurses play a critical role in reducing preventable harm among inpatients. This cross-sectional survey of nurses working in general medicine wards identified both enabling factors (behavioral regulation, perceived capabilities, and environmental context/resources) and barriers (intentions, perceived consequences, optimism, and professional role) to implementing comprehensive harm prevention programs for older adult inpatients.
Gilbert GL, Kerridge I. BMC Health Serv Res. 2022;22:504.
Hospital transmission of COVID-19 has necessitated review of organization infection prevention and control (IPC) policies and practices. This study, conducted before the pandemic, compared IPC attitudes and practices of nurses and physicians, and how these differences affect interpersonal relationships. Both professions described unflattering and stereotypical behaviors of the other (i.e., doctors are unaware or disdainful of IPC; “bossy” nurses). Many IPC policies implemented during the pandemic, such as encouraging all healthcare workers to speak up about infection prevention breaches, were accepted by both professions, and the authors recommend seizing on this interprofessional unity to continue adherence to all IPC policies.
Wailling J, Kooijman A, Hughes J, et al. Health Expect. 2022;Epub Mar 23.
Harm resulting from patient safety incidents can be compounded if investigating responses ignore the human relationships involved. This article describes how compounded harm arises, and it recommends the use of a restorative practices. A restorative approach focuses on (1) who has been hurt and their needs, and who is responsible for addressing those needs, (2) how harms and relationships can be repaired, and avenues to prevent the incident from reoccurring.
Tham N, Fazio T, Johnson D, et al. World J Surg. 2022;46:1249-1258.
The COVID-19 pandemic led to changes in infection control and prevention measures to limit nosocomial spread. This retrospective cohort study found that escalations in infection prevention and control practices due to the COVID-19 pandemic did not affect the incidence of other hospital-acquired infections among surgical patients at one Australian hospital. The authors posit that this may be due to high compliance with existing infection prevention and control practices pre-pandemic.
Tee QX, Nambiar M, Stuckey S. J Med Imaging Radiat Oncol. 2022;66:202-207.
Diagnostic errors in radiology can result in treatment delays and contribute to patient harm. This article provides an overview of the common cognitive biases encountered in diagnostic radiology that can contribute to diagnostic error, and strategies to avoid these biases, such as the use of a cognitive bias mitigation strategy checklist, peer feedback, promoting a just culture, and technology approaches including artificial intelligence (AI).
Paulik O, Hallen J, Lapkin S, et al. J Patient Saf. 2022;18:e613-e619.
Patient falls are considered a never event and can result in serious injury. This study retrospectively reviewed inpatient falls resulting in injury and the strength of the improvement recommendations proposed after investigation of the event. The researchers classified 8.5% of recommendations as ‘strong’ (i.e., environmental modifications, equipment/process redesign), 35.7% as ‘medium’ (i.e., changing documentation process and/or skill mix, providing education) and 55.8% as ‘weak’ (i.e., alerts or warnings).
Latimer S, Hewitt J, de Wet C, et al. J Clin Nurs. 2022;Epub Mar 6.
Medication reconciliation at hospital discharge has become a mainstay of patient safety efforts with most of the focus on pharmacist involvement. Focus groups of hospital nurses were conducted to elicit their perspectives on their role in medication reconciliation. Three themes emerged: nurses' role involves chasing, checking, and educating; burden of undertaking medication reconciliation at hospital discharge; team collaboration and communication in medication reconciliation.
Adverse drug events are common and often result in preventable patient harm. Based on 23 included studies from US and international settings, this meta-analysis estimated that drug-related deaths contributed to 5.6% of all inpatient hospital deaths. The authors estimated that almost half of drug-related deaths are preventable.
Mimmo L, Harrison R, Travaglia J, et al. Dev Med Child Neurol. 2022;64:314-322.
Children with intellectual disabilities may experience poor-quality care and be at higher risk for patient safety events. This cross-sectional study including patients admitted to two children’s hospitals in Australia found that children with intellectual disabilities had longer hospital stays and experienced more admissions with at least one clinical incident (e.g., medication incidents, documentation errors) compared to children without intellectual disabilities.
Long JA, Webster CS, Holliday T, et al. Simul Healthc. 2022;17:e38-e44.
Simulation training is a valuable tool to improve patient care. In this study, researchers explored latent safety threats identified during multidisciplinary simulation-based team training delivered to 21 hospitals in New Zealand. Common latent threats were related to knowledge and skills, team factors, task- or technology-related factors, and work environment threats.
Adamson L, Beldham‐Collins R, Sykes J, et al. J Med Radiat Sci. 2021;Epub Dec 9.
Reporting of near misses and adverse events can provide a foundation for learning from error. This quality improvement project surveyed radiation oncology staff in two local health districts to assess understanding and use of incident learning systems, barriers to reporting or needs for process change, and perception of departmental safety culture. System processes (e.g., takes too long) were identified as barriers to reporting more frequently than safety culture (e.g., fear of negative action towards self or others).
Moore MR, Mitchell SJ, Weller JM, et al. Anaesthesia. 2021;77:185-195.
Surgical safety checklists (SSCs) have been shown to improve patient outcomes and reduce complications. In this study, postoperative mortality and increased days alive and out of hospital were measures for surgical patients in the 18-month period prior to implementation of the SSC and the 18-month period following implementation. Changes in mortality and days alive and out of hospital during these time periods were indistinguishable from longer-term trends. Researchers noted Māori patients had worse outcomes than non-Māori patients.
Brown B, Bermingham S, Vermeulen M, et al. BMJ Open Qual. 2021;10:e001593.
Despite evidence of the benefits of the World Health Organization’s surgical safety checklist, implementation and sustainability are inconsistent in many hospitals. Using five cycles of Plan-Do-Study-Act, a hospital in Adelaide, South Australia, was able to increase use of the checklist from 3.5% to 63%. Staff reported that they felt the new checklist process improved patient safety and was easily incorporated into their workflow.
Wallis KA, Elley CR, Moyes SA, et al. BJGP Open. 2022;6:BJGPO.2021.0129.
Common high-risk medications such as antiplatelets and non-steroidal anti-inflammatory drugs (NSAIDs) have the potential to cause serious patient harm. This randomized trial examined the usefulness of an existing intervention to support safer prescribing in general practice to improve safe high-risk prescribing.
Ellis LA, Tran Y, Pomare C, et al. BMC Health Serv Res. 2021;21:1256.
This study investigated the relationship between hospital staff perceived sociotemporal structures, safety attitudes, and work-related well-being. The researchers identified that hospital “pace” plays a central role in understanding that relationship, and a focus on “pace” can significantly improve staff well-being and safety attitudes.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.