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Arriaga AF, Sweeney RE, Clapp JT, et al. Anesthesiology. 2019;130:1039-1048.
Debriefing after a critical event is a strategy drawn from high reliability industries to learn from failures and improve performance. This retrospective study of critical events in inpatient anesthesiology practice found that debriefing occurred in 49% of the incidents. Debriefs were less likely to occur when critical communication breakdowns were involved, and more than half of crisis events included at least one such breakdown. Interviews with care teams revealed that communication breakdowns present in some incidents impeded the subsequent debriefing process. The authors call for more consistent implementation of debriefing as a recommended patient safety process. A previous WebM&M commentary discussed an incident involving miscommunication between a surgeon and an anesthesiologist.
Martin G, Khajuria A, Arora S, et al. J Am Med Inform Assoc. 2019;26:339-355.
This systematic review examined whether mobile technology has been shown to improve teamwork or communication in acute care settings. Few studies met methodological quality standards, but researchers conclude that mobile technology holds promise to enhance safety through improved teamwork and communication in hospital settings.
Lynn LA. Patient Saf Surg. 2019;13:6.
Artificial intelligence (AI) technologies can improve the use of data in care delivery. This review recommends steps to enhance the use of AI in bedside care. The author highlights the need for clinicians to accept that AI tools will affect care processes and be trained to participate in AI integration on the front line.
Rosenbaum L. N Engl J Med. 2019;380:684-688.
Breakdowns in communication and teamwork are common contributors to adverse events and can compromise safety. As medical care becomes more complex, more teams and subspecialists are involved in a patient's care, which may lead to fragmentation of care and a lack of clear ownership. This three-part series on teamwork highlights the challenges surrounding interprofessional communication and collaboration in today's health care environment, with an emphasis on the resultant adverse effects for patients. The first commentary describes a scenario in which many consultants were carefully considering a patient's case but were not communicating effectively with one another. The second commentary underscores how psychological safety can facilitate improved collaboration and error disclosure among teams. In the third part of the series, the author points out that although the practice of medicine is highly dependent on effective teamwork, medical culture continues to emphasize and even heroize the individual to its own detriment. The author suggests that further research is necessary to achieve optimal teamwork in medicine. A PSNet interview discussed the importance of leadership and teamwork in health care.
Lawton R, Robinson O, Harrison R, et al. BMJ Qual Saf. 2019;28:382-388.
Risk aversion in clinical practice may lead to the ordering of unnecessary tests and procedures, a form of overuse that may pose harm to patients. Experienced clinicians may be more comfortable with uncertainty and risk than less experienced providers. In this cross-sectional study, researchers surveyed doctors working in three emergency departments to understand their level of experience and used vignettes to characterize their reactions to uncertainty and risk. They found a significant association between more clinical experience and less risk aversion as well as a significant association between more experience and greater ease with uncertainty. The authors caution that they cannot draw conclusions on how these findings impact patient safety. An accompanying editorial suggests that feedback is an important mechanism for improving confidence in clinical decision-making. A WebM&M commentary discussed risks related to overdiagnosis and medical overuse.
Pattni N, Arzola C, Malavade A, et al. Br J Anaesth. 2019;122:233-244.
Effective teamwork and communication are critical to ensuring patient safety in the busy environment of the operating room. This review examined the evidence on preparing staff to challenge authority in the perioperative environment. Common themes that affect speaking up included hierarchy, organizational culture, and education. Teaching that promotes open communication in the postgraduate environment and utilizing tactics such as simulation training can help address barriers to challenging authority.
Meyer AND, Singh H. JAMA. 2019;321:737-738.
Safe diagnosis is a complex challenge that requires multidisciplinary approaches to achieve lasting improvement. Effective feedback is a primary component of individual, team, and organizational learning. This commentary describes how creating pathways within an organization that enable physicians to provide and receive feedback about diagnostic performance can limit overdiagnosis and overuse.
Sahlström M, Partanen P, Azimirad M, et al. J Nurs Manag. 2019;27:84-92.
This survey of medical inpatients at five academic medical centers in Finland aimed to elicit patients' perceptions of safety and experience of errors. Investigators found that encouragement from staff, education about patient safety, and comprehensible information all led to higher participation rates. The authors conclude that patients will be more engaged in their safety if frontline staff value patient involvement.
Levy AG, Scherer AM, Zikmund-Fisher BJ, et al. JAMA Netw Open. 2018;1:e185293.
Diagnostic errors and delays may occur when patients fail to disclose medically relevant information. This study analyzed online survey responses from 4510 patients and found that about 70% reported not disclosing information. Disagreement with a clinician's recommendation or failure to understand a clinician's instructions were common. Patients most often did not disclose because they feared judgment from the clinician or felt embarrassed.
Khan A, Spector ND, Baird JD, et al. BMJ. 2018;363:k4764.
Patient engagement in safety takes many forms: patients may report unique safety incidents, encourage adherence to best medical practice, and coproduce improvement initiatives. Family-centered rounding in pediatrics invites families to express concerns, clarify information, and provide real-time input to the health care team. This pre–post study explored the safety impact of family-centered rounds on 3106 admissions in pediatric units at 7 hospitals. Family-centered rounds reduced both preventable and nonpreventable adverse events. They also improved family experience without substantially lengthening rounding time. A past PSNet interview discussed the safety benefits of structured communication between health care providers and family members.
Pérez T, Moriarty F, Wallace E, et al. BMJ. 2018;363:k4524.
Elderly patients are at greater risk of experiencing adverse drug events than the adult population as a whole. Older patients are more likely to be frail, have more medical conditions, and are physiologically more sensitive to injury from certain classes of medication. Researchers examined a large cohort of Irish outpatients age 65 and older to determine the relationship between hospital discharge and potentially inappropriate medication prescribing. Approximately half of the 38,229 patients studied were prescribed a medication in contravention to the STOPP criteria. The risk of potentially inappropriate prescribing increased after hospital discharge, even when using multiple statistical techniques to control for medical complexity. An accompanying editorial delineates various vulnerabilities that predispose older patients to adverse events during the transition from hospital to home. A recent PSNet perspective discussed community pharmacists' role in promoting medication safety.
Nickel WK, Weinberger SE, Guze PA, et al. Ann Intern Med. 2018;169:796-799.
Patient and family engagement can enhance both individual safety and organizational improvement efforts. This position paper advocates for patients and families to be active partners in all aspects of their care, treated with respect and dignity, engaged in improving health care systems, and directly involved in education of health care professionals. The piece also provides strategies to employ these recommendations in the daily practice.
Barr D, Epps QJ. J Thromb Thrombolysis. 2019;47:146-154.
Anticoagulants are commonly prescribed medications that have high potential for harm if administered incorrectly. This review summarizes common errors at the prescribing, dispensing, and administration phases of direct oral anticoagulant therapy. The authors suggest team-based strategies—such as process assessment, policy development, and medication reconciliation—to prevent adverse drug events associated with direct oral anticoagulants.
Mann S, Hollier LM, McKay K, et al. New Engl J Med. 2018;379:1689-1691.
Maternal morbidity has received increasing attention as a patient safety issue. This commentary recommends four strategies for improving obstetrics safety: focusing on prevention of complications, using multidisciplinary huddles to enhance communication, employing simulation as a teamwork training model, and developing partnerships between hospitals to ensure the best care is available.
Vento S, Cainelli F, Vallone A. World J Clin Cases. 2018;6:406-409.
Malpractice concerns can influence treatment decisions as clinicians seek to avoid errors of omission. This commentary reviews factors that contribute to defensive medicine, underscores the role the blame culture has in perpetuating this behavior, and discusses the costs to patients, physicians, and health systems.
Giardina TD, Haskell H, Menon S, et al. Health Aff (Millwood). 2018;37:1821-1827.
Reducing harm related to diagnostic error remains a major focus within patient safety. While significant effort has been made to engage patients in safety, such as encouraging them to report adverse events and errors, little is known about patient and family experiences related specifically to diagnostic error. Investigators examined adverse event reports from patients and families over a 6-year period and found 184 descriptions of diagnostic error. Contributing factors identified included several manifestations of unprofessional behavior on the part of providers, e.g., inadequate communication and a lack of respect toward patients. The authors suggest that incorporating the patient voice can enhance knowledge regarding why diagnostic errors occur and inform targeted interventions for improvement. An Annual Perspective discussed ongoing challenges associated with diagnostic error. The Moore Foundation provides free access to this article.
Fisher KA, Smith KM, Gallagher TH, et al. BMJ Qual Saf. 2019;28:190-197.
Patients are frequently encouraged to engage with health care providers as partners in safety by speaking up and sharing their concerns. Although research has shown that patients and family members sometimes identify safety issues that might otherwise go unnoticed, they may not always be willing to speak up. In this cross-sectional study involving eight hospitals, researchers used postdischarge patient survey data to understand patients' comfort in voicing concerns related to their care. Almost 50% of the 10,212 patients who responded to the survey reported experiencing a problem during hospitalization, and 30% of those patients did not always feel comfortable sharing their concerns. An Annual Perspective summarized approaches to engaging patients and caregivers in safety efforts.
Schiff GD, Martin SA, Eidelman DH, et al. Ann Intern Med. 2018;169:643-645.
Safe diagnosis is a complex challenge that requires multidisciplinary approaches to achieve lasting improvement. The authors worked with a multidisciplinary panel to build a 10-element framework outlining steps that support conservative diagnosis. Recommendation highlights include a renewed focus on history-taking and physician examination, as discussed in a PSNet perspective. They also emphasize the importance of continuity between clinicians and patients to build trust and foster timely diagnosis. Taken together with recommendations for enhanced communication between specialist and generalist clinicians and more judicious use of diagnostic testing, this report is a comprehensive approach to reducing overdiagnosis and overtreatment.
Fønhus MS, Dalsbø TK, Johansen M, et al. Cochrane Database Syst Rev. 2018;9:CD012472.
Engaging patients in their care can enhance safety, quality, and satisfaction. The Joint Commission and Centers for Medicare and Medicaid Services both call for health care organizations to encourage patient engagement in their care. This review and meta-analysis assessed which patient engagement strategies improve clinician adherence to recommended clinical practice. Two strategies had moderate impact: enhancing the information elicited from patients and educating patients about best clinical practice. Patient decision aids did not affect clinician performance, and the authors were unable to determine how interventions impacted health outcomes. A PSNet perspective explored novel avenues for patient engagement that leverage health information technology.
Ramani S, Könings KD, Mann K, et al. Acad Med. 2018;93:1348-1358.
Constructive feedback is a pillar of strong safety culture. Through resident and attending physicians focus groups at a single institution, investigators found that cultural emphasis on politeness and excellence hindered all parties' ability to provide honest feedback. The authors advocate for transitioning to a culture of growth, which would shift their institution toward a more just culture.