Articles of Interest Uncovering Latent Failures Using Human Factors Approach as a Diagnostic Tool for Quality Improvement in Orthopedic Surgery
Khan, A, Cohen, T, Shappell, S & Boquet, A. (2025). Uncovering Latent Failures Using Human Factors Approach as a Diagnostic Tool for Quality Improvement in Orthopedic Surgery. American Journal of Medical Quality, 40, 255-260. https://doi.org/10.1097/JMQ.0000000000000265
Abstract
Human factors significantly influence medical quality, especially in complex environments like orthopedic surgery, where latent failures can compromise patient safety. A total of 3168 intraoperative events were observed across 40 orthopedic procedures and classified using the Human Factors Analysis and Classification System (HFACS). Three trained coders independently applied HFACS across 4 tiers and 19 causal categories. Interrater reliability was measured through percent agreement and Fleiss' Kappa using unanimous, majority, and reconciled coding conditions. Nearly all observed disruptions (98.97%) were classified as preconditions to unsafe acts, most (68.75%) stemmed from crew resource management failures, distractions from personal electronic devices, poor communication, and sales representative presence. A total of 19.47% of disruptions were due to personal readiness, due to the sales representation supporting role in ensuring technologies. An additional 5.87% were due to physical environment issues like equipment noise.
Conclusions: The HFACS framework demonstrated strong reliability in identifying systemic weaknesses within orthopedic surgical workflows. These findings emphasize the urgent need for structured interventions that reduce distractions, improve team communication, and regulate vendor interactions in the operating room, all essential steps toward advancing safety and enhancing overall patient care quality.
Abbott Sued by Patient After Early Replacement of Trifecta GT Heart Valve
(2026). Abbott Sued by Patient After Early Replacement of Trifecta GT Heart Valve. Biomedical Safety & Standards, 56 (6), 161-162. doi: 10.1097/01.BMSAS.0001189116.40558.60.
Excerpt:
A patient whose Trifecta GT heart valve failed 6 years after implantation has sued Abbott Laboratories.1
Ronald Luckey of Kentucky is suing Abbott for negligence after his heart valve required replacement less than 6 years after it was implanted. The device exhibited structural valve deterioration (SVD) that was detected by Luckey's physicians.
The patient underwent implantation of the Abbott Trifecta GT valve in the fall of 2018. In September 2024, the valve displayed signs of SVD. The lawsuit states that the expected life cycle of the valve was at least 15 years, and that Abbott breached multiple warranties.
Potential applications of artificial intelligence with large datasets for predicting food biotoxicity
Xing, Kuoran , Wang, Qiang , Dadol, Glebert Cañete , et al Food Quality and Safety , vol 26 no 10, February 2026.
Abstract
Food safety is a critical global concern, as toxic substances in food pose serious risks to public health. With the rise of novel
Aligning Patient Safety Event Reporting: 2025 Updates to Sentinel Events and Serious Reportable Events
Joint Commission Journal on Quality and Patient Safety, The , March 01, 2026, Volume 52, Issue 3, Pages 130-132
Abstract
The following report was issued by Joint Commission and the National Quality Forum on January 26, 2026. The report aligns Joint Commission’s Sentinel Events (SE) List and NQF’s recently updated Serious Reportable Events (SRE) List, thereby streamlining safety event reporting and eliminating the need to maintain separate safety measurement frameworks. The intent is to reduce confusion and burden, while placing greater focus on improving patient safety.
First introduced in 1996, Joint Commission’s SE List is used by accredited healthcare organizations to track, study, and improve prevention of patient safety events that result in death, permanent harm, or severe temporary harm. NQF’s SRE List, launched in 2002, comprises a subset of patient safety events that are serious and largely preventable and may be indicative of a problem with a healthcare setting’s underlying safety systems.
Because of this report’s importance to those working in healthcare quality and safety , The Joint Commission Journal on Quality and Patient Safety provides excerpts in this issue: the executive summary of the report as well as the updated list of serious reportable events. Read the full report here: Aligning Patient Safety Event Reporting .
Hospital Employees View Patient Safety Culture Differently According to Their Role
Quigley, D, Elliott, M, Schulson, L & Dick, A. (2026). Hospital Employees View Patient Safety Culture Differently According to Their Role. Journal of Patient Safety, 22, 101-106. https://doi.org/10.1097/PTS.0000000000001431
Abstract
Objectives Limited evidence exists about differences in patient safety culture by employee role. We examine the relationship between role and patient safety culture.
Methods Using 2021 to 2022 Hospital Survey on Patient Safety Culture (HSOPS) cross-sectional data (245,252 HSOPS respondents, 371 hospitals), we fit separate employee/respondent-level OLS regression models for 10 aspects of patient safety culture and 2 summary measures as a function of the employee's role, controlling for year, employee and hospital characteristics with hospital-level clustered standard errors (SEs) weighted to represent the nation.
Results C-suite/executive/senior leaders reported the highest proportions of positive ratings for overall patient safety and all 10 aspects of patient safety culture. Managers/supervisors were most likely and unit staff (assistants/secretaries/clerks) were least likely to report safety events. Physicians reported the lowest proportion of positive overall patient safety ratings and ratings for communication and improvement. Care aides reported the lowest for teamwork, staffing/work pace, and response-to-error, nurses lowest for hospital management support and pharmacists lowest for handoffs and information exchange.
Conclusions C-suite/executives/senior leaders, supervisors and managers have different perspectives of patient safety culture than physicians, care aides, nurses, and staff, revealing the need to improve patient safety culture for those who provide direct patient care and to improve communication across leaders and all employee roles. Hospitals should focus on improving communication and management support related to patient safety for physicians and on teamwork, staffing and work pace for care aides. Understanding the root of variability in how pharmacists assist and support patient handoffs and information exchange and how physicians, care aides and staff communicate, accept managerial input, and learn from errors are critical as they may affect safety and event reporting. Hospital leaders could also hold discussions at the microclimate level (unit) for those doing well and those not doing to discuss focusing on the culture of patient safety performance. Ensuring that communication is open and transparent across all hospital employees is critical to providing safe, effective patient care.
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