CE: Using Smart IV Infusion Pumps Outside of Patient Rooms.

The COVID-19 pandemic has created unique challenges for health care workers, who have demonstrated dedication, collaboration, and innovation in response. In this article, the authors describe an important nursing innovation they employed at Montefiore Medical Center in the Bronx, New York, during the spring 2020 COVID-19 surge: the relocation of smart IV infusion pumps outside of patient rooms. The goals of this innovation were to improve delivery of care, conserve personal protective equipment, limit the spread of the virus, and protect staff from exposure.

In-Hospital Newborn Falls Associated With a Sleeping Parent: The Case for a New Paradigm.

A newborn fall to the floor from a sleeping parent's arms in the immediate postpartum period may result in a skull fracture, head bleed, and transfer to the NICU for observation. These harmful consequences galvanized frontline clinicians to prevent these tragic accidents, but, a decade later, they continue at a stubbornly low, persistent level. In this article, I suggest that a misunderstanding of sleep science may be a barrier to effective interventions.

Blame and its consequences for healthcare professionals: response to Tigard.

Tigard (2019) suggests that the medical community would benefit from continuing to promote notions of individual responsibility and blame in healthcare settings. In particular, he contends that blame will promote systematic improvement, both on the individual and institutional levels, by increasing the likelihood that the blameworthy party will 'own up' to his or her mistake and apologise. While we agree that communicating regret and offering a genuine apology are critical steps to take when addressing patient harm, the idea that medical professionals should continue to 'take the blame' for medical errors flies in the face of existing science and threatens to do more harm than good.

Patients' Perspectives of Engagement as a Safety Strategy.

Purpose/objectives: To describe patient engagement as a safety strategy from the perspective of hospitalized surgical patients with cancer.
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Research Approach: Qualitative, descriptive approach using grounded theory.

A conceptual framework for patient-centered fertility treatment.

Background: Patient-centered care is a pillar of quality health care and is important to patients experiencing infertility. In this study we used empirical, in-depth data on couples' experiences of infertility treatment decision making to inform and revise a conceptual framework for patient-centered fertility treatment that was developed based on health care professionals' conceptualizations of fertility treatment, covering effectiveness, burden, safety, and costs.

Methods: In this prospective, longitudinal mixed methods study, we collected data from both members (separately) of 37 couples who scheduled an initial consult with a reproductive specialist.

Priorities for family building among patients and partners seeking treatment for infertility.

Background: Infertility treatment decisions require people to balance multiple priorities. Within couples, partners must also negotiate priorities with one another. In this study, we assessed the family-building priorities of couples prior to their first consultations with a reproductive specialist.

Accountability: Challenges to Getting It Right.

Patient safety experts debated accountability in health care at the 2014 annual National Patient Safety Foundation Congress. The debate reflected the struggles organizations are facing with ensuring a responsible workforce committed to patient safety versus the need to redesign flawed systems that are error prone. The question, "is it the systems or the individual?" was at issue.

A one-to-one mentoring support service for breast cancer survivors.

Purpose: ABCD: After Breast Cancer Diagnosis (ABCD) is a Wisconsin-based mentoring service that pairs breast cancer survivors with women recently diagnosed with breast cancer. Since 1999, ABCD has trained volunteers to provide personalized information and emotional support. This review describes participants' perceptions of this survivorship program and its utility for breast cancer patients.

Recognizing and managing errors of cognitive underspecification.

Objectives: James Reason describes cognitive underspecification as incomplete communication that creates a knowledge gap. Errors occur when an information mismatch occurs in bridging that gap with a resulting lack of shared mental models during the communication process. There is a paucity of studies in health care examining this cognitive error and the role it plays in patient harm.

Patient-provider communication about gestational weight gain among nulliparous women: a qualitative study of the views of obstetricians and first-time pregnant women.

Background: In 2009 the Institute of Medicine updated its guidelines for weight gain during pregnancy, in part because women of childbearing age now weigh more pre-pregnancy and tend to gain more weight during pregnancy than women did when the previous set of guidelines were released in 1990. Women who begin pregnancy overweight or obese and women who gain weight outside IOM recommendations are at risk for poor maternal and fetal health outcomes. With these concerns in mind, we examined what obstetricians communicate about gestational weight gain to their pregnant patients and how nulliparous patients perceive weight-related counseling from their obstetricians.

Positioning medical students for the geriatric imperative: using geriatrics to effectively teach medicine.

Medical schools must consider innovative ways to ensure that graduates are prepared to care for the aging population. One way is to offer a geriatrics clerkship as an option for the fulfillment of a medical school's internal medicine rotation requirement. The authors' purpose was to evaluate the geriatrics clerkship's impact on internal medicine knowledge and medical student attitudes toward older adults.

Application of human error theory in case analysis of wrong procedures.

Objectives: The goal of this study was to contribute to the emerging body of literature about the role of human behaviors and cognitive processes in the commission of wrong procedures.

Methods: Case analysis of 5 wrong procedures in operative and nonoperative settings using James Reason's human error theory was performed.

Results: The case analysis showed that cognitive underspecification, cognitive flips, automode processing, and skill-based errors were contributory to wrong procedures.

Unrecognized hypoglycemia due to maltodextrin interference with bedside glucometry.

Introduction: Glucometry is widely used to confirm or exclude hypoglycemia in patients with suggestive clinical findings. Nonglucose sugars may be detected by certain types of glucometers, causing false elevation of the glucometer analysis of the blood sugar. Since these other sugars are not functionally glucose and may even induce excess insulin release, clinical hypoglycemia may be missed.