The PSNet Collection

Society for Maternal-Fetal Medicine Special Statement: Cognitive bias and medical error in obstetrics-challenges and opportunities.

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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.

Challenges of Diabetes Management and Medication Reconciliation

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August 5, 2022

This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to compile the ‘best possible medication history’, and how pharmacy staff roles and responsibilities can reduce medication errors.

Preventing retained surgical items.

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Weston M, Chiodo C. AORN J. 2022;115:569-575.

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.

Undiagnosed and rare diseases in critical care: the role of diagnostic access.

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Bordini BJ. Crit Care Clin. 2022;38:159-171.

Rare diseases can present diagnostic challenges to clinicians. This article discusses how cognitive biases can impede diagnosis of rare conditions and strategies to improve diagnostic safety in critical care, such as diagnostic timeouts.

Can the standard configuration of a cardiac monitor lead to medical errors under a stress induction?

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Dzisko M, Lewandowska A, Wudarska B. Sensors (Basel). 2022;22:3536.

Interruptions and distractions in healthcare settings can inhibit safe care. This simulation study found that medical staff reaction time to changes in vital signs during stressful situations (telephone ringing, ambulance signal) was significantly slower than during non-stressful situations, which may increase the likelihood of medical errors.

Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.

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July 8, 2022

A 58-year-old man with a past medical history of seizures presented to the emergency department (ED) with acute onset of left gaze deviation, expressive aphasia, and right-sided hemiparesis. The patient was evaluated by the general neurology team in the ED, who suspected an acute ischemic stroke and requested an evaluation by the stroke neurology team but did not activate a stroke alert. The stroke team concluded that the patient had suffered a focal seizure prior to arrival and had postictal deficits.

Prevention of perioperative medication errors.

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Nanji K. UpToDate. June 23, 2022.

Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical setting and discusses prevention strategies that focus on medication reconciliation, technology, standardization, and institutional change.

Antifatness in the surgical setting.

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Andreou A. Scientific American. May 26, 2022.

Negative comments and attitudes indicate a lack of professionalism that can affect patient care. This article shares concerns about surgeon biases toward patients who are overweight and calls for clinicians to recognize the problem and address it.

Safety gaps in medical team communication: closing the loop on quality improvement efforts in the cardiac catheterization lab.

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Doorey AJ, Turi ZG, Lazzara EH, et al. Catheter Cardiovasc Interv. 2022;99:1953-1962.

Closed loop communication (CLC) ensures a clear transfer of information by having the recipient repeat the order for verification. In this study, procedures in the cardiac catheterization lab were observed to assess the frequency and accuracy of CLC. Despite three interventions over five years (education, on-going feedback, accountability), CLC remained suboptimal, with both incomplete orders given and incomplete responses.

Automated dispensing cabinet overrides-an evaluation of necessity in a pediatric emergency department.

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Paterson EP, Manning KB, Schmidt MD, et al. J Emerg Nurs. 2022;48:319-327.

Automated dispensing cabinets (ADCs) can reduce medication dispensing errors by requiring pharmacist verification. This study found that medication overrides (i.e., bypassing pharmacist review before administration) in one pediatric emergency department were frequently not due to an emergent situation requiring immediate medication administration and could have been avoided.

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports.

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Baartmans MC, Hooftman J, Zwaan L, et al. J Patient Saf. 2022;Epub Apr 21.

Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.

The effects of leadership curricula with and without implicit bias training on graduate medical education: a multicenter randomized trial.

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Hansen M, Harrod T, Bahr N, et al. Acad Med. 2022;97:696-703.

Strong physician leadership during clinical crisis can help improve patient outcomes. In this randomized controlled trial, obstetrics-gynecology and emergency medicine residents participated in one of three study arms using high-fidelity mannequins. One study arm received a bespoke leadership curriculum, one received a modified version TeamSTEPPS curriculum, and the third received no leadership training. Participants in both curriculum arms improved leadership scores from “average” before the training to “good” following the training and continuing to six months. The control arm remained unchanged at “average” before and after.

Observational evidence of the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients.

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Savva G, Papastavrou E, Charalambous A, et al. Sr Care Pharm. 2022;37:200-209.

Polypharmacy is an established problem among older adult patients and can lead to medication errors and adverse events. This observational study concluded that polypharmacy was common among adult patients (ages 21 and older) at one tertiary hospital, with almost half of inpatients prescribed more than 9 drugs during their hospitalization. Findings indicate that medication administration errors increase as the number of prescribed drugs increased.

Management of Cardiac Arrest in Unconventional Locations.

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May 16, 2022

This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms.

Clinician distress and inappropriate antibiotic prescribing for acute respiratory tract infections: a retrospective cohort study.

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Brady KJS, Barlam TF, Trockel MT, et al. Jt Comm J Qual Patient Saf. 2022;48:287-297.

Inappropriate prescribing of antibiotics to treat viral illnesses is an ongoing patient safety threat. This study examined the association between clinician depression, anxiety, and burnout and inappropriate prescribing of antibiotics for acute respiratory tract infections (RTIs) in outpatient care. Depression and anxiety, but not burnout, were associated with increased adjusted odds of inappropriate prescribing for RTIs.

Compensation claims in Danish emergency care: identifying hot spots and blind spots in the quality of care.

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Morsø L, Birkeland S, Walløe S, et al. Jt Comm J Qual Patient Saf. 2022;48:271-279.

Patient complaints can provide insights into safety threats and system weaknesses. This study used the healthcare complaints analysis tool (HCAT) to identify and categorize safety problems in emergency care. Most problems arose during examination/diagnosis and frequently resulted in diagnostic errors or errors of omission.

Communication patterns during routine patient care in a pediatric intensive care unit: the behavioral impact of in situ simulation.

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Ulmer FF, Lutz AM, Müller F, et al. J Patient Saf. 2022;18:e573-e579.

Closed-loop communication is essential to effective teamwork, particularly during complex or high-intensity clinical scenarios. This study found that participation in a one-day simulation team training for pediatric intensive care unit (PICU) nurses led to significant improvements in closed-loop communication in real-life clinical situations.

Patient Safety Authority Annual Reports.

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Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.

This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.

Conversations on diagnostic uncertainty and its management among pediatric acute care physicians.

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Patel SJ, Ipsaro A, Brady PW. Hosp Pediatr. 2022;Epub Feb 28.

Diagnostic uncertainty can arise in complex clinical scenarios. This qualitative study explored how physicians in pediatric emergency and inpatient settings mitigate diagnostic uncertainty. Participants discussed common mitigation strategies, such as employing a “diagnostic pause.” The authors also noted outstanding gaps regarding communicating diagnostic uncertainty to families.

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Staal J, Speelman M, Brand R, et al. BMC Med Educ. 2022;22:256.

Diagnostic safety is an essential component of medical training. In this study, medical interns reviewed six clinical cases in which the referral letters from the general practitioner suggested a correct diagnosis, an incorrect diagnosis, or lacked a diagnostic suggestion. Researchers found that diagnostic suggestions in the referral letter did not influence subsequent diagnostic accuracy but did reduce the number of diagnoses considered.

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