Busch IM, Moretti F, Purgato M, et al. J Patient Saf. 2020;16:e61-e74.
The second victim phenomenon refers to the emotional impact adverse events and patient harm can have on health care team members, including physicians and nurses. This meta-analysis sought to quantify psychological and psychosomatic symptoms experienced by second victims. Researchers identified 18 studies and found that embarrassment, guilt, regret, self-recrimination, anxiety, fear of future errors, reliving the incident, and difficulty sleeping were the most common symptoms. These results underscore how involvement in errors can have detrimental consequences for provider well-being. The authors recommend both preventive programs and postevent support for health care workers after medical errors. A PSNet interview with Albert Wu, who coined the term second victim, discussed approaches to address this safety issue.
Clarkson MD, Haskell H, Hemmelgarn C, et al. BMJ. 2019;364:l1233.
The term "second victim," coined by Dr. Albert Wu, has engendered mixed responses from patients and health care professionals. This commentary raises concerns that the term negates the sense of responsibility for errors that result in harm and advocates for abandoning it.
Sutherland A, Ashcroft DM, Phipps DL. Arch Dis Child. 2019;104:588-595.
Using clinical vignettes, investigators conducted semi-structured interviews with those prescribing medications in a pediatric intensive care unit to better understand human factors contributing to prescribing errors. They found that cognitive load was the main contributor to such errors.
Kaufman RM, Dinh A, Cohn CS, et al. Transfusion (Paris). 2019;59:972-980.
Wrong-patient errors in blood transfusion can lead to serious patient harm. Research has shown that use of barcodes to ensure correct patient identification can reduce medication errors, but less is known about barcoding in transfusion management. This pre–post study examined the impact of barcode labeling on the rate of wrong blood in tube errors. Investigators found that use of barcoding improved the accuracy of labels on blood samples and samples that had even minor labeling errors had an increased chance of misidentifying the patient. The authors conclude that the results support the use of barcoding and the exclusion of blood samples with even minor labeling errors in order to ensure safe blood transfusion. An accompanying editorial delineates the complex workflow, hardware, and software required to implement barcoding for transfusion. A past WebM&M commentary discussed an incident involving a mislabeled blood specimen.
Hessels AJ, Paliwal M, Weaver SH, et al. J Nurs Care Qual. 2019;34:287-294.
This cross-sectional study examined associations between safety culture, missed nursing care, and adverse events. Investigators found significant associations between worse ratings of safety culture and more reports of missed nursing care. They recommend enhancing safety culture to reduce missed nursing care and improve safety.
Timely and accurate diagnosis is a prerequisite for safe and high-quality treatment. This study used data from the Human Diagnosis Project (Human Dx, an online case-solving platform) to examine diagnostic accuracy among individual physicians compared to groups of physicians (collective intelligence). Physicians can enter cases onto the platform or solve cases that others have entered. The more physicians involved in solving a given case, the more likely that the correct diagnosis would be identified. Groups of physicians across specialties outperformed individual subspecialists even for subspecialty-relevant cases. The authors advocate for testing the use of collective intelligence for diagnosis in clinical settings. A related editorial discusses how teaching diagnosis has evolved and the possibility of using collective intelligence to improve diagnostic accuracy. In a previous PSNet interview, Shantanu Nundy, Director of Human Dx, discussed his work with the project.
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.
Griffiths P, Ball JE, Bloor K, et al. National Institute for Health Research; 2018.
Missed nursing care has been linked to safety problems, but ensuring reliable levels of nurse staffing remains challenging. This report provides the results of a 3-year investigation into whether tracking of vital signs by nursing staff could serve as a viable measure for safe patient coverage. The report identified correlations between low staffing, missed vital sign observation, length of stay, and likelihood of mortality. However, record review found no direct relationship between safety and staffing levels. A PSNet perspective examined the relationship between missed nursing care and patient safety.
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.
Steelman VM, Shaw C, Shine L, et al. Jt Comm J Qual Patient Saf. 2019;45:249-258.
An unintentionally retained foreign object during a surgery or a procedure is considered a never event and can result in significant patient harm. Researchers retrospectively reviewed 308 events involving unintentionally retained foreign objects that were reported to The Joint Commission to better characterize these events, determine the impact on the patient, identify contributing factors, and make recommendations for improving safety.
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.
Tubbs-Cooley HL, Mara CA, Carle AC, et al. JAMA Pediatr. 2019;173:44-51.
Excessive nursing workload is a known safety issue. This study examined whether nurse workload in the neonatal intensive care unit affected the quality of nursing care. Investigators measured workload using patient–nurse ratios, taking into account patient acuity, and a convenience sample of nurses also reported their perceived workload. Participating nurses were asked to report the care they provided, and missed care was defined as self-reported failure to provide any of 11 prespecified essential elements of nursing care. The authors identified a consistent association between perceived workload and missed care, suggesting that nurses' own assessments of their workload should be a safety consideration. A PSNet perspective explores how missed nursing care may explain the association between low nurse staffing levels and increased mortality in hospital patients.
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.
Duffy JR, Culp S, Padrutt T. J Nurs Adm. 2018;48:361-367.
Prior research has shown that missed nursing care may in part result from reduced nurse staffing and is associated with adverse outcomes for patients. Using survey data from a sample of nurses at a single community hospital, researchers found that reduced nurse staffing, lower job satisfaction, and decreased satisfaction with teamwork were important factors related to missed nursing care.
Billstein-Leber M, Carrillo CJD, Cassano AT, et al. Am J Health-Syst Pharm. 2018;75:1493-1517.
Pharmacists can play an important role in medication error reduction efforts across health care systems. This document provides recommendations and best practices for health-system pharmacists to improve safety throughout the medication-use process.
Mitchell BG, Gardner A, Stone PW, et al. Jt Comm J Qual Patient Saf. 2018;44:613-622.
Lack of appropriate staffing can diminish the safety and effectiveness of medical services. In this systematic review, researchers found that increased hospital staffing was generally associated with decreased rates of health care–associated infections.
Overuse of tests and treatments can contribute to negative consequences for patients. This commentary suggests that clarification is required to engage clinicians in reducing overuse-related harm and proposes a six-domain framework that delineates areas of concern to target improvement strategies. A previous WebM&M commentary highlighted a case in which health care overuse resulted in a patient's death.
Ratwani RM, Savage E, Will A, et al. J Am Med Inform Assoc. 2018;25:1197-1201.
In this simulation study, emergency department physicians completed standardized tasks using actual electronic health records (EHRs) at four sites. Even though two sites used Epic and two used Cerner EHRs, the number of clicks per task, time to task completion, and error rates varied widely. The authors highlight the importance of local implementation decisions as well as design and development in supporting usability and safety of electronic health records.
Schnipper JL, Mixon A, Stein J, et al. BMJ Qual Saf. 2018;27:954-964.
The goal of medication reconciliation is to prevent unintended medication discrepancies at times of transitions in care, which can lead to adverse events. Implementing effective medication reconciliation interventions has proven to be challenging. In this AHRQ-funded quality improvement study, five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators. The toolkit was implemented at each study site by a pharmacist and a hospitalist with support from local leadership. The intervention did not achieve overall reduction in potentially harmful medication discrepancies compared to baseline temporal trends. However, significant differences existed between the study sites, with sites that successfully implemented the recommended interventions being more likely to achieve reductions in harmful medication discrepancies. The study highlights the difficulty inherent in implementing quality improvement interventions in real-world settings. A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices.
Rodriguez-Gonzalez CG, Herranz-Alonso A, Escudero-Vilaplana V, et al. J Eval Clin Pract. 2019;25:28-35.
Pharmacy robots are now commonly used in hospitals for dispensing medications. Conducted at a Spanish hospital, this study found that use of pharmacy robots reduced medication dispensing errors and improved staff efficiency. The role of a pharmacy robot in a serious medication error is explored in a book that examined the effects of technological change on the health care system.
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