Kappes M, Romero‐García M, Delgado‐Hito P. Int Nurs Rev. 2021;68:471-481.
Healthcare professionals who experience negative physical, psychological, or behavioral responses following an adverse event may be referred to as “second victims.” This review describes personal and organizational support strategies as well as barriers faced by second victims who are seeking support. The authors recommend further evaluation of support programs and implementation of support programs in Latin America.
Della Torre V, E. Nacul F, Rosseel P, et al. Anaesthesiol Intensive Ther. 2021;53:265-270.
Human factors (HF) is the interaction between workers, equipment, and the environment. The COVID-19 pandemic has accelerated the adoption of HF in intensive care units across the globe. This paper expands on the core concepts of HF and proposes the additional key concepts of agility, serendipity, innovation, and learning. Adoption of these HF concepts by leadership and staff can improve patient safety in intensive care units in future pandemics and other crisis situations.
Clinical pharmacist involvement has improved medication safety in several clinical areas. Using the therapeutic outcome monitoring (TOM) method, pharmacists in this study identified 43 negative outcomes associated with oral chemotherapy medication and performed 81 pharmaceutical interventions. The TOM method increased patient safety by improving the use of medications.
Dutra CK dos R, Guirardello E de B. J Adv Nurs. 2021;77:2398-2406.
This cross-sectional study describes the relationship between nurse work environment and missed nursing care, safety culture, and job satisfaction. Nurses who perceived a positive work environment reported reduced reasons for missed nursing care, an improved safety culture, and increased job satisfaction. Reasons for missed care were primarily related to lack of leadership support and resources. Nurse managers can increase perception of a positive work environment by providing additional support and adequate human and material resources.
Tartari E, Saris K, Kenters N, et al. PLoS One. 2020;15.
Presenteeism among healthcare workers can lead to burnout and healthcare-associated infections, but prior research has found that significant numbers of healthcare workers continue to work despite having influenza-like illness. This study surveyed 249 healthcare workers and 284 non-healthcare workers from 49 countries about their behaviors when experiencing influenza-like illness between October 2018 and January 2019. Overall, 59% of workers would continue to work when experiencing influenza-like illness, and the majority of healthcare workers (89.2-99.2%) and non-healthcare workers (80-96.5%) would continue to work with mild symptoms, such as a mild cough, fatigue or sinus cold. Fewer non-healthcare workers (16.2%) than healthcare workers (26.9%) would continue working with fever alone.
Sodré Alves BMC, de Andrade TNG, Cerqueira Santos S, et al. J Patient Saf. 2021;17:e1-e9.
This systematic review analyzed five studies discussing adverse events due to medical errors involving high-alert medications. The authors estimated the pooled prevalence at 16.3%, but the included studies reported a wide variation in prevalence (from 3.8% to 100%). The studies also reported a wide range in error severity – up to 19.2% were considered moderate, up to 15.4% were considered serious, and up to 1.9% were considered lethal. The most common medication administration errors involved insulin, potassium chloride, and epoprostenol.
Barbanti-Brodano G, Griffoni C, Halme J, et al. Eur Spine J. 2019.
Checklists are one tool for improving communication and reducing risk of adverse outcomes. The World Health Organization Surgical Safety Checklist has been previously studied in various surgical specialties; this study sought to determine its effectiveness in spinal surgeries. The authors conducted a retrospective analysis comparing the incidence of complications pre-checklist and post-checklist in a single center and found a significant reduction in the overall incidence of complications after the introduction of the checklist.
Lemos C de S, Poveda V de B. J Perianesth Nurs. 2019;34:978-998.
This integrative review examined the factors contributing to perioperative adverse events resulting from anesthesia. Researchers found that both active errors, such as medication errors or inattention, and latent errors, such as communication failures, contributed to adverse events.
Garcia C de L, de Abreu LC, Ramos JLS, et al. Medicina (Kaunas). 2019;55:553.
New meta-analysis on potential impacts of provider burnout concludes a relationship exists between high levels of burnout—from factors such as high workload and ineffective interpersonal relationships—and worsening patient safety.
Castro-Avila A, Bloor K, Thompson C. J Health Serv Res Policy. 2019;24:182-190.
In the United States, unannounced accreditation inspections are deployed extensively to evaluate hospital safety. This interrupted time-series analysis found that enhanced accreditation procedures in the United Kingdom did not improve rates of either pressure ulcers or falls. In a PSNet interview, the president of The Joint Commission discussed how accrediting bodies can help achieve high reliability.
Johnston BE, Lou-Meda R, Mendez S, et al. BMJ Glob Health. 2019;4.
Medical errors are a concern across the economic spectrum worldwide. This commentary describes an educational effort to develop champions to lead patient safety, quality improvement, and infection control initiatives in health systems in low- and middle-income countries. The authors highlight the importance of contextualizing training to consider local needs and resources.
Freitas PS, Silveira RC de CP, Clark AM, et al. J Clin Nurs. 2016;25:1835-47.
Retained surgical items are considered a never event, but they continue to occur. Summarizing the evidence on surgical counts, this review explores risk factors, current processes, and technology solutions to determine best practices for perioperative nurses to prevent instances of retained surgical items.
Boniatti MM, Azzolini N, Viana M, et al. Crit Care Med. 2014;42:26-30.
Rapid response teams have been widely implemented in hospitals, despite mixed evidence of their benefits. This prospective observational study demonstrated that delayed calls to the rapid response team were associated with higher 30-day mortality.
Plebani M, ed. Clinica Chimica Acta. 2009;404(1):1-86.
This collection of papers presented at an international conference on laboratory medicine focuses on efforts to reduce medical errors in laboratory practice, especially those concerning diagnostic mistakes.
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