Pitts SI, Yang Y, Woodroof T, et al. J Patient Saf. 2022;18:e934-e937.
CancelRx is a health information tool designed to improve communication between electronic health record (EHR) systems and pharmacy dispensing software. This study found that CancelRx implementation eliminated the sale of electronically prescribed medications after discontinuation in the EHR, compared to prior to implementation. Researchers found that CancelRx did result in the unintentional cancellation of some prescriptions and they discuss the importance of situational awareness among providers and pharmacy staff to mitigate this issue.
The COVID-19 pandemic increased symptoms of physician burnout, including emotional exhaustion, which can increase patient safety risks. This cross-sectional study examined emotional exhaustion among healthcare workers at two large health care systems in the United States before and during the COVID-19 pandemic. Respondents reported increases in emotional exhaustion in themselves and perceived exhaustion experienced by their colleagues. The researchers found that emotional exhaustion was often clustered in work settings, highlighting the importance of organizational climate and safety culture in mitigating the effects of COVID-19 on healthcare worker well-being.
Hunter J, Porter M, Williams B. Australas Emerg Care. 2022;Epub Aug 29.
Situational awareness (SA) requires recognizing situations, interpreting them, and predicting how the situation may unfold in the future. Paramedics and emergency medical technicians (EMT) participated in a video simulation to assess their SA at each of the three stages. Quantitative results indicated the providers were not situationally aware during the simulation.
McTaggart LS, Walker JP. Health Sci Rev. 2022;4:100049.
Burnout is a significant problem among medical residents. This literature review characterizes the state of the evidence regarding resident burnout and professionalism. The authors discuss the evidence supporting the relationship between burnout and medical errors, poor quality patient care, and poor academic performance.
Hodkinson A, Zhou, A, Johnson J, et al. BMJ. 2022;378:e070442.
Clinician burnout is a significant issue that can impact patient safety. This systematic review and meta-analysis showed physicians with burnout were significantly more dissatisfied with their jobs, were more regretful of their chosen career path, and had higher intention to leave their jobs. The association between burnout and patient satisfaction, patient safety, and professionalism is also discussed.
Clinicians involved in adverse events may experience feelings of guilt, shame, and inadequacy; this is referred to as “second victim” phenomenon. In this study of pediatric surgeons and surgical trainees, 84% experienced a poor patient outcome. Responses to the adverse event varied by level of experience (e.g., resident, attending), gender, and age.
Westbrook JI, McMullan R, Urwin R, et al. Intern Med J. 2022;Epub Aug 24.
The COVID-19 pandemic dramatically impacted team functioning in healthcare settings. This survey of nearly 1,600 clinical and non-clinical staff at five Australian hospitals did not identify any perceived increases in unprofessional behaviors during the pandemic and 44% of respondents cited improvements in teamwork.
Brown TH, Homan PA. Health Serv Res. 2022;57:443-447.
Structural racism, from race-adjusted algorithms to biased machine learning, contributes to and exacerbates health inequities. This commentary calls for developing valid measures of structural racism and a publicly available data infrastructure for researchers. A related study examined the relationship between structural racism and birth outcomes between Black and white patients in Minnesota.
Luri M, Gastaminza G, Idoate A, et al. J Patient Saf. 2022;18:630-636.
Clinical decision support systems can alert prescribers to potential interactions between the drug being ordered and other drugs or drug allergies. Earlier studies have shown high rates of overrides of drug allergy alerts. This study analyzed allergic adverse drug events that occurred because of overridden drug allergy alerts (ODAA). Less than 10% of ODAA were inappropriate and resulted in only mild adverse events.
Obstetric and gynecologic (OB/GYN) physicians are frequently involved in malpractice lawsuits, some of which result in catastrophic payouts. This study categorized malpractice claims involving OB/GYN trainees (students, residents, and fellows) between 1986 and 2020. Cases are categorized by type of injury, patient outcome, category of error, outcome of lawsuit, and amount of settlement.
Thiruchelvam K, Byles J, Hasan SS, et al. Res Social Adm Pharm. 2022;18:3758-3765.
Potentially inappropriate medications (PIMs) are common among older adults living in residential care facilities. This study examined the impact of the Australian Residential Medication Management Review (RMMR) service (a patient-centered medication review program) on PIM prescribing among older women living in residential aged care facilities. Researchers identified no evidence of an association between the medication review program and use of PIMs in the following year.
Wawersik D, Palaganas J. J Healthc Manag. 2022;67:283-301.
Organizational cultures encouraging psychological safety can increase safe healthcare practices such as error reporting. This narrative review identified several organizational factors that promote psychological safety and error reporting (e.g., leadership support, nonpunitive and fair blame cultures, and continuous improvement processes) as well as organizational factors that serve as barriers to reporting (e.g., blame culture, poor communication, burnout, leadership resistance to change).
Lim Fat GJ, Gopaul A, Pananos AD, et al. Geriatrics (Basel). 2022;7:81.
The risk of adverse events increases with prolonged hospital stays. This descriptive study examined adverse events among older patients with extended hospital admissions pending transfer to long-term care (LTC) settings at two Canadian hospitals. Analyses showed that patients were designated as “alternate level of care” (ALC) for an average of 56 days before transfer to LTC and adverse events such as falls and urinary tract infections were common.
Apodaca C, Casanova-Perez R, Bascom E, et al. J Am Med Inform Assoc. 2022;Epub Aug 19.
Minoritized patients who experience implicit or overt discrimination in healthcare report receiving lower quality of care and may avoid seeking care in the future altogether. In this study, patients who identify as Black, Indigenous, People of Color (BIPOC), and/or Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ+) describe their experiences of unfair treatment and discrimination in healthcare. Four themes related to immediate reactions and six themes related to long-term coping emerged.
Gogalniceanu P, Kunduzi B, Ruckley C, et al. Surgery. 2022;172:537-545.
The patient safety field frequently adapts safety methods from aviation, such as checklists and crew resource management. Drawn from fieldwork, interviews with aviation safety experts, and focus groups with patient safety experts, this study adapted interventions from aviation crisis recovery for use in surgical error recovery. Twelve tools were developed based on three broad strategies: situational awareness and workload management; checklists for non-normal situations; decision making and problem solving.
Nijor S, Rallis G, Lad N, et al. J Patient Saf. 2022;18:e999-e1003.
Usability issues related to electronic health record (EHR) use among clinicians can contribute to burnout and threaten patient safety. This literature review outlines how EHR usability issues, such as information overload, can lead to errors and threaten patient safety. The authors suggest that future research explore methods to mitigate EHR overload-related errors, including the role of EHR usability.
Staal J, Hooftman J, Gunput STG, et al. BMJ Qual Saf. 2022;Epub Sep 2.
Enhancing clinical reasoning skills is an emerging strategy to reduce diagnostic errors. This meta-analysis of 26 studies estimated that cognitive reasoning tools can lead to small improvements in diagnostic accuracy.
Moore T, Kline D, Palettas M, et al. J Nurs Care Qual. 2022;Epub Aug 19.
Fall prevention is a safety priority in hospital settings. This study found that Smart Socks – socks containing pressure sensors that detect when a patient is trying to stand up – reduced fall rates among patients at risk of falls in one hospital’s neurological and neurosurgical department. Over a 13-month period, investigators observed a decreased fall rate (0 per 1000 patient days) among patients wearing Smart Socks compared to prior to intervention implementation (4 per 1000 patient days).
Kraemer KL, Althouse AD, Salay M, et al. JAMA Health Forum. 2022;3:e222263.
Nudges (e.g., default order sets) in the electronic health record (EHR) have been shown to encourage safer prescribing of opioids in emergency departments. This study evaluated the effect of nudges to reduce opioid prescribing for opioid-naïve patients with acute pain. Primary care practices were cluster randomized to control, opioid justification in the EHR, peer comparison, or combined opioid justification and peer comparison groups. The three intervention groups showed reduced opioid prescribing compared to control.
Linzer M, Sullivan EE, Olson APJ, et al. Diagnosis (Berl). 2022;Epub Aug 22.
Challenging working conditions and increased cognitive workload can result in stress and burnout. This article describes a conceptual framework in which working conditions and cognitive workload impact stress and burnout, which, in turn, impacts diagnostic accuracy. Potential uses and testing of the framework are described.
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