jueves, 1 de agosto de 2019

Fatigue in radiology: a fertile area for future research. | AHRQ Patient Safety Network

Fatigue in radiology: a fertile area for future research. | AHRQ Patient Safety Network

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Review
Published May 2019

Fatigue in radiology: a fertile area for future research.

Taylor-Phillips S, Stinton C. Br J Radiol. 2019;92:20190043.

Physician fatigue is associated with risk of error, but less is known about this issue in radiology care outcomes. This review analyzes the research on this topic and calls for an enhanced examination of how radiologist fatigue directly relates to error. The authors describe study designs that can help further the understanding needed to drive improvement.

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Flawed self-assessment in hand hygiene: a major contributor to infections in clinical practice? | AHRQ Patient Safety Network

Flawed self-assessment in hand hygiene: a major contributor to infections in clinical practice? | AHRQ Patient Safety Network

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Study
Published March 2019

Flawed self-assessment in hand hygiene: a major contributor to infections in clinical practice?

Kelcikova S, Mazuchova L, Bielena L, Filova L. J Clin Nurs. 2019;28:2265-2275.

This survey study found that physician and nurse self-assessments of their hand hygiene was better than their observed adherence with hand hygiene guidelines. Participants also rated their own hand hygiene higher, on average, than their peers. The authors recommend more direct observation of hand hygiene to prevent health care–associated infections.

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PEARLS for systems integration: a modified PEARLS framework for debriefing systems-focused simulations. | AHRQ Patient Safety Network

PEARLS for systems integration: a modified PEARLS framework for debriefing systems-focused simulations. | AHRQ Patient Safety Network

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Commentary
Published May 2019

PEARLS for systems integration: a modified PEARLS framework for debriefing systems-focused simulations.

Dubé MM, Reid J, Kaba A, et al. Simul Healthc. 2019 May 21; [Epub ahead of print].

Simulation is used to assess process and team performance and prevent failure. This commentary discusses the Promoting Excellence And Reflective Learning in Simulation (PEARLS) framework and how the modifiable debriefing strategies in the framework can help identify system-level problems and implement changes to enhance patient safety.

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Walking the plank: an experimental paradigm to investigate safety voice. | AHRQ Patient Safety Network

Walking the plank: an experimental paradigm to investigate safety voice. | AHRQ Patient Safety Network

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Study
Published April 2019

Walking the plank: an experimental paradigm to investigate safety voice.

Noort MC, Reader TW, Gillespie A. Front Psychol. 2019;10:668.

This psychological experiment sought to measure speaking-up behaviors of medical students and the general public, using a masked experiment rather than asking participants to report their behaviors or comfort level. Investigators found that though participants were more likely to speak up when they received specific information about safety risks in an experimental situation, many still chose to remain silent about unsafe conditions. They also found differences in participants' reported willingness to speak up compared to their observed behavior, suggesting that behavioral experiments are important to enhance speaking up for safety.

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Development and performance evaluation of the Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists' input to prevent medication-related problems. | AHRQ Patient Safety Network

Development and performance evaluation of the Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists' input to prevent medication-related problems. | AHRQ Patient Safety Network

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Study
Published March 2019

Development and performance evaluation of the Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists' input to prevent medication-related problems.

Geeson C, Wei L, Franklin BD. BMJ Qual Saf. 2019;28:645-656.

This article describes the development and validation of a scoring tool to identify patients most at risk for adverse drug events. The authors suggest that an external validation study is needed to determine whether this tool accurately predicts which patients could benefit most from pharmacist consultation during hospitalization.

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High-alert medication administration and intravenous smart pumps: a descriptive analysis of clinical practice. | AHRQ Patient Safety Network

High-alert medication administration and intravenous smart pumps: a descriptive analysis of clinical practice. | AHRQ Patient Safety Network

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Study
Published February 2019

High-alert medication administration and intravenous smart pumps: a descriptive analysis of clinical practice.

Marwitz KK, Giuliano KK, Su WT, Degnan D, Zink RJ, DeLaurentis P. Res Social Adm Pharm. 2019;15:889-894.

This retrospective study of smart infusion pump use across multiple hospitals found that the majority of pump alerts are overridden by clinicians, regardless of the type of pump or whether the medication is a high-alert medication. These results suggest a need to augment alerting algorithms to prevent alert fatigue and improve safety.

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