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.
AI-Enabled Medical Devices Drive Nearly Half of All Recalls in First Year After 510(k) Approval
(2026). AI-Enabled Medical Devices Drive Nearly Half of All Recalls in First Year After 510(k) Approval. Biomedical Safety & Standards, 56 (3), 143-144. doi: 10.1097/01.BMSAS.0001179456.60494.10.
Excerpt:
A recent study in JAMA Health Forum found that artificial intelligence-enabled medical devices (AIMDs), nearly all of which are cleared via the 510(k) approval pathway, account for a much higher rate of early recalls compared with other types of devices.
Inulin as a multifunctional prebiotic: from gut modulation to systemic health benefits
Sanlier, Nevin , Keskin, Mihriye Gül , and Oz, Fatih
Inulin as a multifunctional prebiotic: from gut modulation to systemic health benefits, Food Quality and Safety, This article is not yet published in a specific volume/issue.
Abstract
In recent years, plant-based nutrition has attracted great interest worldwide. Inulin is a soluble prebiotic dietary fiber derived from plants that enhances digestive health by modulating the gut microbiota. It is fermented by Bifidobacterium and Lactobacillus species, resulting in the production of short-chain fatty acids, which promote gut barrier integrity, immune equilibrium, metabolic health, and overall systemic wellness. Additionally, it enhances the production of short7 chain fatty acids, strengthens gut barrier function, and reduces inflammation. As a prebiotic, it is fermented by colon bacteria. Prebiotics positively influence the gut microbiota due to their ability to be selectively utilized by beneficial bacteria through specific enzymatic activities. Based on this biological relevance, this review summarizes recent evidence on the structural characteristics, functional properties, and health effects of inulin. A comprehensive literature search (2017–2025) was conducted using major electronic databases, such as MEDLINE, the Cochrane Library, CINAHL, ClinicalTrials.gov, Scopus, Google Scholar, and Web of Science, identifying 130 studies investigating its influence on gastrointestinal function, metabolic regulation, inflammation, and chronic disease outcomes. This evidence indicates that inulin supplementation can reduce intestinal inflammation, improve lipid and glucose metabolism, and modulate the gut–brain axis. However, variations in dose, degree of polymerization (DP), host condition, and baseline microbiota composition have contributed to inconsistent or even adverse responses across studies. Overall, inulin represents a multifunctional dietary ingredient with promising clinical potential. To fully utilize its benefits, future research should focus on standardized clinical protocols, DP-specific evaluations, and long term safety assessments to guide the development of next-generation prebiotic formulations tailored to individual microbiome profiles.
Personalized Video Education in Surgical Consent: Lessons from a Diverse Safety-Net Population
Monasterio, Diego , Hanson, Nicole , Diaz, Graal , et al, Joint Commission Journal on Quality and Patient Safety.
This article is not yet published in a specific volume/issue.
Abstract
Background
A key component of shared decision-making (SDM) is education. This manuscript explores the role of videos as supplements to traditional decision-making, focusing on custom videos for surgical patients
Methods
This study aims to assess the impact of customized video education on traditional surgical consent procedures. This is a prospective cohort study that took place at a county safety-net hospital in California, USA, involving patients undergoing surgical treatment from August 2023 through January 2025. After surgical consultation, each patient received an electronically sent customized educational video addressing indications, procedures, and risks in the patient’s preferred language. After watching the videos, SDM was evaluated using the CollaboRATE scale and questions evaluating satisfaction with video education.
Results
204 patients participated: 134 English-speakers (EN) and 70 Spanish-speakers (SP). SP were older, with 48.6% aged 45–64 vs. 21.6% of EN (p < 0.001). Educational differences existed with 39.6% of EN reporting college degrees compared to 11.4% among SP (p < 0.001). The video types watched were 51.2% Gallbladder, 5.4% Appendix, 20.5% Breast, 16.1% Skin surgery, and 4.5% others. Both groups (94.77% of EN and 97.14% SP) expressed preference for video education over written. EN achieved CollaboRATE Top Scores more frequently (67.9% vs. 54.3%, p = 0.08). EN outperformed SP in knowing available treatment options (100.0% vs. 91.04%, p < 0.01), understanding benefits (95.49% vs. 82.86%, p < 0.01), and recognizing risks and side effects (91.3% vs. 80.0%, p = 0.05).
Conclusions
Customized video education for surgery leads to high rates of understanding treatment options, benefits, and risks. However, disparities between English and Spanish-speakers reveal that language plays a critical role in patient engagement and perceived support. This suggests a need for targeted improvements in educational resources for Spanish-speaking patients to ensure equitable access to information and support.
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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