In-hospital mortality associated with the misdiagnosis or unidentified site of infection at admission.

Abe T, Tokuda Y, Shiraishi A, et al; JAAM SPICE Study Group. Crit Care. 2019;23:202.

This retrospective study sought to determine whether timely diagnosis of the site of infection affected in-hospital mortality for sepsis. Investigators found that patients whose infection site was misdiagnosed on admission had more than twofold greater odds of dying in the hospital compared to those with the correct infection site diagnosed on admission. These results reinforce the importance of correct and timely diagnosis for sepsis outcomes.

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Medication safety alert fatigue may be reduced via interaction design and clinical role tailoring: a systematic review. | AHRQ Patient Safety Network

Medication safety alert fatigue may be reduced via interaction design and clinical role tailoring: a systematic review. | AHRQ Patient Safety Network

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Review
Published June 2019

Medication safety alert fatigue may be reduced via interaction design and clinical role tailoring: a systematic review.

Hussain MI, Reynolds TL, Zheng K. J Am Med Inform Assoc. 2019 Jun 17; [Epub ahead of print].

This systematic review examined the override rates of several different clinical decision support approaches. Researchers conclude that role tailoring—the provision of different alerts to prescribers versus pharmacists—was the most successful method to reduce alert fatigue. They recommend redesigning decision support to reduce alert fatigue.

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Study of a multisite prospective adverse event surveillance system. | AHRQ Patient Safety Network

Study of a multisite prospective adverse event surveillance system. | AHRQ Patient Safety Network

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Study
Published July 2019

Study of a multisite prospective adverse event surveillance system.

Forster AJ, Huang A, Lee TC, Jennings A, Choudhri O, Backman C. BMJ Qual Saf. 2019 Jul 3; [Epub ahead of print].

This prospective study used a trigger tool approach to identify potential adverse events among hospitalized patients in real time. Researchers found widely varying adverse rates among the five hospitals and concluded that event detection among the trigger event reviewers was responsible for some of the variation in observed events. These results underscore the challenge of accurate adverse event surveillance.

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Duration of second victim symptoms in the aftermath of a patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands. | AHRQ Patient Safety Network

Duration of second victim symptoms in the aftermath of a patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands. | AHRQ Patient Safety Network

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Study
Published July 2019

Duration of second victim symptoms in the aftermath of a patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands.

Vanhaecht K, Seys D, Schouten L, et al; Dutch Peer Support Collaborative Research Group. BMJ Open. 2019;9:e029923.

Clinicians may experience distress after being involved in adverse events. This study of 4369 Dutch providers examined the prevalence and duration of clinicians' symptoms associated with involvement in an adverse event as well as the relationship between the degree of harm and symptom duration. As expected, clinicians reported symptoms such as hypervigilance, self-doubt, and discomfort following adverse events. These symptoms were more severe and long lasting for events with more serious harm to patients, compared to events with less severe harm. The authors call for organizations to provide support for clinicians involved in adverse events. A previous PSNet perspective discussed efforts to ameliorate the impact of errors on providers.

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Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. | AHRQ Patient Safety Network

Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. | AHRQ Patient Safety Network

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Study
Published July 2019

Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis.

Panagioti M, Khan K, Keers RN, et al. BMJ. 2019;366:l4185.

The extent of harm due to patient safety problems varies across studies. This systematic review sought to estimate the prevalence of preventable harm in medical care overall. Researchers synthesized data from 70 studies and estimated that 6% of patients receiving medical care experience preventable harm. Harm related to medications, diagnosis, health care–associated infections, and procedures accounted for significant proportions of preventable harm. The authors conclude that focusing on evidenced-based strategies to address preventable patient harm would improve health care quality and subsequently reduce costs. A related editorial calls for improving measurement of preventable harm. Another editorial spotlights the importance of understanding the causes of preventable harm in health care.

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