Etheridge JC, Moyal-Smith R, Sonnay Y, et al. Int J Surg. 2022;98:106210.
Non-technical skills such as communication, teamwork, decision-making, and situational awareness are responsible for a significant proportion of surgical errors. The COVID-19 pandemic increased the stress in the operating room, associated with increased risk of exposure and shortage of resources. This study compared pre- and post-COVID direct observations during live operations and found that non-technical skills were equivalent; there was a small, but statistically significant, improvement in teamwork and cooperation skills.
Murata M, Nakagawa N, Kawasaki T, et al. Am J Emerg Med. 2022;52:13-19.
Transporting critically ill patients within a hospital (e.g., to radiology for diagnostic procedures) is necessary but also poses safety threats. The authors conducted a systematic review and meta-analysis of all types of adverse events, critical or life-threatening adverse events, and death occurring during intra-hospital transport. Results indicate that adverse events can occur in intra-hospital transport, and that frequency of critical adverse events and death are low.
Linguistic, culture, and health literacy barriers between patients and providers can lead to adverse events. In addition to the use of professional interpreters, the authors suggest additional culturally and linguistically appropriate services (CLAS) to improve communication between patients, particularly refugees and migrants, and providers.
Panda N, Sinyard RD, Henrich N, et al. J Patient Saf. 2021;17:256-263.
The COVID-19 pandemic has presented numerous challenges for the healthcare workforce, including redeploying personnel to different locations or retraining personnel for different tasks. Researchers interviewed hospital leaders from health systems in the United States, United Kingdom, New Zealand, Singapore and South Korea about redeployment of health care workers during the COVID-19 pandemic. The authors discuss effective practices and lessons learned preparing for and executing workforce redeployment, as well as concerns regarding redeployed personnel
Parush A, Wacht O, Gomes R, et al. J Med Internet Res. 2020;22:e19947.
This study surveyed healthcare professionals in Israel and Portugal to identify key human factors that influence the use of personal protective equipment (PPE) when caring for patients with suspected or confirmed COVID-19. Respondents attributed difficulties in wearing PPE to discomfort, challenges in hearing and seeing, and doffing. Analyses also found an association between PPE discomfort and situational awareness, but this association reflected difficulties in communication (e.g., hearing and understanding speech).
Using a social and behavioral sciences perspective, the authors present insights for aligning behavior with recommendations from experts for managing the COVID-19 pandemic and its impact. Topics include threat perception, leadership, individual and collective interests, science communication, social context, and stress and coping.
This article describes the use of strong matrix management and the plan-do-check-act cycle in the management of severe COVID-19 patients in one hospital in China. These tools were used to ensure efficient task delegation in healthcare teams and quality care for COVID-19 patients.
Cai H, Tu B, Ma J, et al. Med Sci Monit. 2020;26:e924171.
Production pressure – the pressure to continue to work at maximum capacity – presents risks to patient safety. This study reported on a survey of 534 healthcare providers and hospital staff in the Hunan province of China about the psychological impact of COVID-19. Respondents cited moral and social responsibility as being the strongest driver to continue working long hours during the outbreak and expressed anxiety and concerns regarding their safety, the safety of their families, and high mortality among their patients. Recognition of healthcare staff by hospital management and government, strong infection control guidelines, and specialized equipment and facilities for the management of COVID‑19 were reported as factors that mitigated psychological burnout.
Almalki H, Absi A, Alghamdi A, et al. JAMA Netw Open. 2020;3.
Effective communication between patients and physicians is essential to ensuring treatment adherence and improved patient outcomes. This cross-sectional study measured agreement in treatment plan understanding between oncology patients and providers in Saudi Arabia and found that most patients (86.2%) had a suboptimal understanding of their chemotherapy treatment plan. Patients commonly did not understand the planned duration of their treatment or the important toxic effects of chemotherapy.
Aldawood F, Kazzaz Y, AlShehri A, et al. BMJ Open Qual. 2020;9.
This study reports on results of completing TeamSTEPPS training by leadership and staff in the pediatric intensive care unit (PICU) at one hospital in Saudi Arabia. The team implemented a daily safety huddle aimed at improving communication and early identification and timely resolution of patient safety issues. Over a 7-month period, 340 safety issues were addressed; the majority involved infection control and medication errors (32%), communication issues (24%) and documentation issues (17%). The authors observed that the daily huddle addressed misconceptions and misunderstandings between nursing and medical teams leading to improved care delivery.
Huang C-H, Umegaki H, Watanabe Y, et al. PLOS ONE. 2019;14:e0211947.
Various tools for identifying potentially inappropriate medications (PIMs) have been developed. This 5-year prospective cohort study of 196 elderly patients receiving home-based medical services in Japan compared the use of two tools for identifying PIMs, the American Geriatrics Society’s Beers Criteria and the relatively new Screening Tool for Older Person’s Appropriate Prescriptions for Japanese (STOPP-J), to determine the impact of PIMs on hospitalization and mortality rates. PIMs categorized by STOPP-J were associated with hospitalization and mortality, whereas Beers Criteria PIMs were associated with hospitalization only after excluding proton pump inhibitors.
Zhu L, Reychav I, McHaney R, et al. Int J Risk Saf Med. 2019;30:129-153.
Understanding the contributors to adverse events helps to identify ways to prevent future events. This study used natural language processing (NLP) strategies and social network analysis (SNA) to explore the underlying behaviors contributing to adverse events, and suggested institutional-level approaches to reducing these events.
Ardenne M, Reitnauer PG. Arzneimittel-Forschung. 1975;25:1369-79.
This special issue reviews research initiatives exploring persistent challenges associated with the prescription drug misuse epidemic and strategies to monitor and reduce its persistence. Topics covered include the role of the pharmacist in addressing opioid misuse, physician–pharmacist collaboration to improve pain management, and community pharmacy monitoring of opioid dispensing.
Tasai S, Kumpat N, Dilokthornsakul P, et al. J Patient Saf. 2021;17:290-298.
Polypharmacy among older patients can increase the risk of adverse drug events. In this meta-analysis, researchers found that medication reviews performed by community pharmacists among older patients with polypharmacy reduced the risk of emergency department visits.
Ericsson C, Skagerström J, Schildmeijer K, et al. BMJ Qual Saf. 2019;28:657-666.
Patient engagement in safety is considered a best practice and a National Patient Safety Goal, but less is known about patients' perceptions regarding this topic. In this survey study involving 1445 patients in Sweden, researchers found that more than 80% of respondents felt comfortable directing questions to doctors and nurses. Patients who had filed a formal complaint reporting a safety concern were found to believe with greater certainty that the patient perspective can improve the safety of care.
Rönnerhag M, Severinsson E, Haruna M, et al. J Adv Nurs. 2019;75:585-593.
Inadequate communication in obstetrics can compromise safety. In this qualitative study, researchers conducted focus groups of multidisciplinary teams including obstetricians, midwives, and nurses working in a single maternity ward to examine their perceptions of adverse events during childbirth. Analysis of data collected suggests that support for high-quality interprofessional teamwork is important for safe maternity care.
Cleary M, Lees D, Lopez V. Issues Ment Health Nurs. 2018;39:980-982.
Effective apology behaviors improve opportunities for error resolution for clinicians, patients, and families. This commentary highlights the importance of expressing empathy, considering legal implications, and demonstrating individual, leadership, and organizational support of open disclosure.
Kua C-H, Mak VSL, Lee SWH. J Amer Med Direct Assoc. 2019;20:362-372.e11.
This systematic review examined the effects of deprescribing on clinical outcomes among patients in long-term care facilities. Researchers found that interventions in which medications were reviewed according to prespecified criteria resulted in reduced mortality and fewer falls. They recommend that deprescribing guided by medication review be widely implemented in long-term care settings.
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.
Hasan SS, Thiruchelvam K, Kow CS, et al. Expert Rev Pharmacoecon Outcomes Res. 2017;17:431-439.
Pharmacist oversight of medication prescribing is an established safety strategy. This review explores the impact of pharmacists on reducing inappropriate polypharmacy in aged care facilities and the cost-effectiveness of this risk management strategy to substantiate the value of the practice.
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