Weenink J-W, Wallenburg I, Hartman L, et al. BMJ Open. 2022;12:e061321.
There is a long-standing tension between health care regulation and just culture principles. This qualitative study explored the experiences of mental health professionals, managers and other healthcare organization staff, as well as inspectors, regarding the role of healthcare inspectors in enabling a just culture. Three themes emerged – (1) the role of the inspector as both a catalyst for learning and a potential barrier, (2) just culture involves relationships between different layers within and outside the organization, and (3) to enable just culture in which inspectors would strike a balance between organizational responsibility and timely regulatory intervention.
Klopotowska JE, Kuks PFM, Wierenga PC, et al. BMC Geriatr. 2022;22:505.
Adverse drug events (ADE) are common and preventable. In this study, hospital pharmacists met face-to-face with prescribing residents to review medications ordered for older adult inpatients. Preventable and unrecognized ADE decreased following implementation. The most common preventable ADE both before and after implementation occurred during the prescribing stage.
Diagnostic safety is beginning to be established as a systemic, rather than solely an individual performance issue. This report recommends strategies that support systemic work toward diagnostic excellence and selected implementation stories that illustrate success. It is a part of a larger initiative devoted to the improvement of organizational and team activities in tandem with clinical processes to minimize the impact of human error on diagnosis.
Waters TM, Burns N, Kaplan CM, et al. BMC Health Serv Res. 2022;22:958.
Pay-for-performance (P4P) strategies have been used by federal agencies to incentivize high quality care and reduce medical errors. This study used 2007 to 2016 inpatient discharge data from 14 states to compare rates of inpatient quality indicators and patient safety indicators before and after the implementation of the Medicare’s P4P program. Analyses identified limited improvement in quality and patient safety indicators.
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.
Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:B2-B10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.
Anesthesiologists often must oversee multiple surgeries. This study evaluated adult patients from 23 US academic and private hospitals who underwent major surgery between 2010, and 2017, to examine anesthesiologist staffing ratios against patient morbidity and mortality. The authors categorized the staffing into four groups based on the number of operations the anesthesiologist was covering. The study found that increased anesthesiologist coverage was associated with greater risk-adjusted morbidity and mortality of surgical patients. Hospitals should consider evaluating anesthesiology staffing to determine potential increased risks.
Montgomery A, Lainidi O, Johnson J, et al. Health Care Manage Rev. 2022;Epub Jun 16.
When faced with a patient safety concern, staff need to decide whether to speak up or remain silent. Leaders play a crucial role in addressing contextual factors behind employees’ decisions to remain silent. This article offers support for leaders to create a culture of psychological safety and encourage speaking up behaviors.
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.
Halvorson EE, Thurtle DP, Easter A, et al. J Patient Saf. 2022;Epub Jul 6.
Voluntary event reporting (VER) systems are required in most hospitals, but their effectiveness is limited if adverse events (AE) go unreported. In this study, researchers compared rates of AE submitted to the VER against those identified using the Global Assessment of Pediatric Patient Safety (GAPPS) trigger tool to identify disparities based on patient characteristics (i.e., weight, race, English proficiency). The GAPPS tool identified 37 AE in patients with limited English proficiency; none of these were reported to the VER system, suggesting a systematic underreporting of AE in this population.
Plint AC, Newton AS, Stang A, et al. BMJ Qual Saf. 2022;Epub Jul 19.
While adverse events (AE) in pediatric emergency departments are rare, the majority are considered preventable. This study reports on the proportion of pediatric patients experiencing an AE within 21 days of an emergency department visit, whether the AE may have been preventable, and the type of AE (e.g., management, diagnostic). Results show 3% of children experienced at least one AE, most of which were preventable.
Blythe R, Parsons R, White NM, et al. BMJ Qual Saf. 2022;Epub Jun 22.
Early recognition of clinical deterioration in patients is often difficult to detect and often results in poor patient outcomes. This scoping review focused on the delivery and response to deterioration alerts and their impact on patient outcomes. Only four out of 18 studies included in the review reported statistically significant improvements in at least two patient outcomes, Authors suggest that workflow and integration of the early warning system model’s features into the decision-making process may be helpful.
Incident investigations are important tools for uncovering latent factors that facilitate patient harm. This conference will draw from experience in the United Kingdom to discuss how adverse event examinations can improve care provision and will highlight efforts in the United Kingdom to focus on maternity care safety.
Samal L, Khasnabish S, Foskett C, et al. J Patient Saf. 2022;Epub Jul 21.
Adverse events can be identified through multiple methods, including trigger tools and voluntary reporting systems. In this comparison study, the Global Trigger Tool identified 79 AE in 88 oncology patients, compared to 21 in the voluntary reporting system; only two AE were identified by both. Results indicate multiple sources should be used to detect AE.
de Kraker MEA, Tartari E, Tomczyk S, et al. Lancet Infect Dis. 2022;22:835-844.
Hand hygiene is known to be a critical part of effective infection prevention and control. This study examined the level of hand hygiene implementation using the WHO Hand Hygiene Self-Assessment Framework global survey and its drivers. There were 3,206 organizations from 90 different countries that responded. Over half of the participants indicated they had intermediate hand hygiene implementation, particularly those with higher county income levels and facility funding. Implementation of alcohol-based hand rub stations was an important system change associated with improved scores.
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.
Barcode medication administration (BCMA) is one approach to reducing near-miss medication safety events. Researchers used a FOCUS (find-organize-clarify-understand-select) PDSA (plan-do-study-act) methodology to help frontline nursing staff identify gaps in care processes and root causes contributing to poor compliance with barcode medication administration.
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.
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