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Della Torre V, E. Nacul F, Rosseel P, et al. Anaesthesiol Intensive Ther. 2021;53:265-270.
Human factors (HF) is the interaction between workers, equipment, and the environment. The COVID-19 pandemic has accelerated the adoption of HF in intensive care units across the globe. This paper expands on the core concepts of HF and proposes the additional key concepts of agility, serendipity, innovation, and learning. Adoption of these HF concepts by leadership and staff can improve patient safety in intensive care units in future pandemics and other crisis situations.
Dutra CK dos R, Guirardello E de B. J Adv Nurs. 2021;77:2398-2406.
This cross-sectional study describes the relationship between nurse work environment and missed nursing care, safety culture, and job satisfaction. Nurses who perceived a positive work environment reported reduced reasons for missed nursing care, an improved safety culture, and increased job satisfaction. Reasons for missed care were primarily related to lack of leadership support and resources. Nurse managers can increase perception of a positive work environment by providing additional support and adequate human and material resources.
Carvalho IV, Sousa VM de, Visacri MB, et al. Pediatr Emerg Care. 2021;37:e152-e158.
This study sought to determine the rate of pediatric emergency department (ED) visits due to adverse drug events (ADE). Of 1,708 pediatric patients, 12.3% were admitted to the ED due to ADEs, with the highest rates of admission due to neurological, dermatological, and respiratory medications. The authors recommend the involvement of clinical pharmacists to prevent and identify ADEs in the pediatric population, particularly through education of children’s caregivers and health professionals.
Sodré Alves BMC, de Andrade TNG, Cerqueira Santos S, et al. J Patient Saf. 2021;17:e1-e9.
This systematic review analyzed five studies discussing adverse events due to medical errors involving high-alert medications. The authors estimated the pooled prevalence at 16.3%, but the included studies reported a wide variation in prevalence (from 3.8% to 100%). The studies also reported a wide range in error severity – up to 19.2% were considered moderate, up to 15.4% were considered serious, and up to 1.9% were considered lethal. The most common medication administration errors involved insulin, potassium chloride, and epoprostenol.
Mamede S, de Carvalho-Filho MA, de Faria RMD, et al. BMJ Qual Saf. 2020;29:550-559.
There is uncertainty about the effectiveness of cognitive debiasing in reducing bias that can contribute to diagnostic error. Instead of focusing on the process of reasoning, this study examined whether an intervention directed at refining knowledge of a cluster of related disease can ‘immunize’ physicians against bias. Ninety-one internal medicine residents in Brazil were randomized to one of two sets of vignettes (reflecting diseases associated with either chronic diarrhea or jaundice) and compared/contrasted alternative diagnoses. After residents encountered one case of a disease, non-immunized residents twice as likely to give that incorrect diagnosis to a different (but similar) disease, resulting in a 40% decrease in diagnostic accuracy between immunized and non-immunized physicians.
Barbanti-Brodano G, Griffoni C, Halme J, et al. Eur Spine J. 2019.
Checklists are one tool for improving communication and reducing risk of adverse outcomes. The World Health Organization Surgical Safety Checklist has been previously studied in various surgical specialties; this study sought to determine its effectiveness in spinal surgeries. The authors conducted a retrospective analysis comparing the incidence of complications pre-checklist and post-checklist in a single center and found a significant reduction in the overall incidence of complications after the introduction of the checklist.
Lemos C de S, Poveda V de B. J Perianesth Nurs. 2019;34:978-998.
This integrative review examined the factors contributing to perioperative adverse events resulting from anesthesia. Researchers found that both active errors, such as medication errors or inattention, and latent errors, such as communication failures, contributed to adverse events.
Frid S, Zapico V, Mansilla A, et al. Stud Health Technol Inform. 2019;264:581-585.
Clinical provider order entry (CPOE) and clinical decision support systems  (CDSS) are intended to enhance medication safety by reducing errors associated with prescription drugs. This study evaluated a tool allowing pharmacists to record errors or near misses, such as medication omission or unjustified medication stops, and communicate those events to the provider. Although only 29% of physicians accepted the pharmacist’s recommendations, these communicated events led to the provider following 112 recommended changes, which was an acceptance rate of 58%.   
Lermontov SP, Brasil SC, de Carvalho MR. Cancer Nurs. 2019;42:365-372.
Bone marrow transplantation requires complex drug therapy management. This systematic review identified 11 studies reporting both medication prescription and administration errors, as well as issues such illegible writing, polypharmacy, absence of medication reconciliation, and lack of patient education. These errors resulted in a variety of adverse events.  The review identified several prevention measures that can be implemented at the provider-level or systems-level (e.g., computerized prescribing systems).
Castro-Avila A, Bloor K, Thompson C. J Health Serv Res Policy. 2019;24:182-190.
In the United States, unannounced accreditation inspections are deployed extensively to evaluate hospital safety. This interrupted time-series analysis found that enhanced accreditation procedures in the United Kingdom did not improve rates of either pressure ulcers or falls. In a PSNet interview, the president of The Joint Commission discussed how accrediting bodies can help achieve high reliability.
Johnston BE, Lou-Meda R, Mendez S, et al. BMJ Glob Health. 2019;4.
Medical errors are a concern across the economic spectrum worldwide. This commentary describes an educational effort to develop champions to lead patient safety, quality improvement, and infection control initiatives in health systems in low- and middle-income countries. The authors highlight the importance of contextualizing training to consider local needs and resources.
Silva M das DG, Martins MAP, Viana L de G, et al. Br J Clin Pharmacol. 2018;84:2252-2259.
This study, conducted at a Brazilian hospital, found that the IHI Global Trigger Tool had relatively poor accuracy at identifying adverse drug events among hospitalized patients. The accuracy and reliability of trigger tools have been questioned in other studies.
Bejnordi BE, Veta M, van Diest PJ, et al. JAMA. 2017;318:2199-2210.
Diagnostic error is a growing area of focus within patient safety. Artificial intelligence has the potential to improve the diagnostic process, both in terms of accuracy and efficiency. In this study, investigators compared the use of automated deep learning algorithms for detecting metastatic disease in stained tissue sections of lymph nodes of women with breast cancer to pathologists' diagnoses. The algorithms were developed by researchers as part of a competition and their performance was assessed on a test set of 129 slides, 49 with metastatic disease and 80 without. A panel of 11 pathologists evaluated the same slides with a 2-hour time limit and one pathologist evaluated the slides without any time constraints. The authors conclude that some of the algorithms demonstrated better diagnostic performance than the pathologists did, but they suggest that further testing in a clinical setting is warranted. An accompanying editorial discusses the potential of artificial intelligence in health care.
Carlotti APCP, Bachette LG, Carmona F, et al. Am J Clin Pathol. 2016;146:701-708.
This autopsy study demonstrated significant discrepancies between clinical and postmortem diagnoses among children who died in the intensive care unit. These results demonstrate the importance of autopsy as an educational tool for clinical teams to improve patient outcomes.
Freitas PS, Silveira RC de CP, Clark AM, et al. J Clin Nurs. 2016;25:1835-47.
Retained surgical items are considered a never event, but they continue to occur. Summarizing the evidence on surgical counts, this review explores risk factors, current processes, and technology solutions to determine best practices for perioperative nurses to prevent instances of retained surgical items.
Boniatti MM, Azzolini N, Viana M, et al. Crit Care Med. 2014;42:26-30.
Rapid response teams have been widely implemented in hospitals, despite mixed evidence of their benefits. This prospective observational study demonstrated that delayed calls to the rapid response team were associated with higher 30-day mortality.