Quality & safety in the literature: July 2020

Meddings, Jennifer; Gupta, Ashwin; Houchens, Nathan

Retrospective analysis of electronic health records, combined with institutional telecommunication logs, showed incoming telephone call interruptions for paediatric intensive care unit nurses were significantly and temporally associated with medication administration errors Effect of cognitive aids on adherence to best practice in the treatment of deteriorating surgical patients: a randomised clinical trial in a simulation setting JAMA Surgery 27 November 2019 Failure to rescue from a state of clinical deterioration while admitted is a major source of morbidity and mortality in surgical and medical patients Contributors to failure to rescue that have been targets for intervention include uncertainty in who is leading the treatment plan (eg, team leader for a ‘code’ event such as cardiac arrest), too many people with unclear roles attending code events and inability to quickly recall and execute appropriate steps of resuscitation due to infrequent practice of such skills and/or stressful environments 5 Prior studies have found benefit in providing training including ‘mock’ codes Team members are often not used to working together, clinicians are redeployed outside of their usual area of practice and clinical expertise (eg, outpatient physicians now leading inpatient teams) and healthcare providers must quickly learn and anticipate complications arising from COVID-19 infection such as rapidly progressive respiratory failure, acute cardiovascular conditions and venous thromboembolic disease [ ]in the development of expanding clinical teams to function together in a crisis like the COVID-19 pandemic, it is also important to thoughtfully design the emergency response teams and resources available to manage the inevitable emergencies that will arise