Email Updates
October 30, 2019 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports, and more. Past issues of the PSNet Weekly Update are available to browse. WebM&M presents current and past monthly issues of Cases & Commentaries and Perspectives on Safety.
Szymusiak J, Walk TJ, Benson M, et al. Ped Qual Saf. 2019;4:e167.
Encouraging adverse event reporting among health care providers, including medical trainees, is critical to improving patient safety. This qualitative study convened focus groups to elucidate what factors support event reporting among medical residents. Residents were more likely to use reporting tools when they had received training about the process, and identified specific interventions, to encourage reporting, such as role modeling by faculty.
Dewar ZE, Yurkonis T, Attia M. Medicine (Baltimore). 2019;98:e17459.
Poor communication and handoffs between providers have been linked to adverse events. The implementation of a standardized hand-off bundle modeled on the I-PASS tool (incorporating illness severity, patient summary, action list, situational awareness, and synthesis by receiver) in an inpatient family medicine service resulted in a significant reduction in medical errors.
Dubosh NM, Edlow JA, Goto T, et al. Ann Emerg Med. 2019;74:549-561.
Misdiagnosis of a neurologic emergency such as stroke can lead to serious morbidity or mortality. Using a large multi-state database, this study examined the likelihood of readmission or inpatient mortality among patients who were initially discharged with nonspecific diagnoses of headache or back pain and found that 0.5% of headache and 0.2% of back pain patients experienced an inpatient death or serious neurological event after ED discharge. Extrapolated to a national level, this translates to over 55,000 patients with adverse outcomes due to a missed diagnosis for headache or back pain.
Bloodworth LS, Malinowski SS, Lirette ST, et al. J Am Pharm Assoc . 2019;59:896-904.
Medication reconciliation is one potential strategy for preventing adverse events and readmissions. This study examined a pharmacist-led intervention involving collaborations with inpatient and community-based pharmacists to provide pre-discharge and 30-day medication reconciliation. There were indications that this type of intervention can reduce readmission rates, but further investigation in larger populations is necessary.
Rich A, Viney R, Griffin A. J R Soc Med. 2019;112:428-437.
Doctors’ obligation and desire to report patient safety concerns seem fundamental. This qualitative study describes several barriers that are related to timely reporting including fear of consequences, disapproval from the organization, and organizations’ not taking doctor’s concerns seriously all were perceived barriers to reporting. Psychological safety may be an important facilitator of physician error reporting.
Leone TA. Semin Perinatol. 2019;43:151179.
Resuscitations are highly complex interventions, particularly in neonatal settings. Ineffective teamwork, poor communication, and knowledge deficits in the neonatal team can result in adverse patient outcomes. Video is one approach to mitigating these issues by providing education, practice simulations, and skill assessment in order to improve patient care.
Commentary
Connor DM, Durning SJ, Rencic J. Acad Med. 2020;95:1166-1171.
Enhancing clinical reasoning skill, particularly among trainees, is emerging as a strategy to reduce diagnostic error. The authors of this commentary suggests that the Accreditation Council for Graduate Medical Education’s (ACGME) consider revising their core competencies to include clinical reasoning to provide trainees with the tools necessary to monitor and prevent diagnostic errors.
Hagedorn PA, Singh A, Luo B, et al. J Hosp Med. 2020;15:378-380.
Secure text messaging has emerged as one method to improve communication between providers and nurses. This paper discusses concerns over alarm fatigue, communication errors and omitting critical verbal communication and provides proposed solutions to support appropriate and effective use of text messaging in a healthcare setting.
Wu M, Tang J, Etherington N, et al. BMJ Qual Saf. 2020;29:77-85.
Interdisciplinary teamwork is critically important in labor and delivery for anesthesiologists, obstetricians, midwives, and nurses to provide optimal care. This systematic review of interventions designed to improve teamwork found that simulation-based teamwork interventions can improve team performance and morbidity in the labor and delivery setting.
Park M, Giap T-T-T. J Adv Nurs. 2020;76:62-80.
Patients and families are critical partners in identifying and preventing patient safety events. A systematic review found willingness among patients and families engage in safety activities, but barriers such as limited patient/family knowledge, poor communication, and lack of systems-level efforts supporting patient and family engagement may hinder effective engagement.
Westman M, Takala R, Rahi M, et al. World Neurosurg. 2019.
Checklists have been shown to improve patient safety in various surgical specialties but this systematic review found that evidence of their impact in neurosurgery is still limited given emerging technologies such as robotics and artificial intelligence. Studies with larger neurosurgical patient populations, as well as in relation to robotic neurosurgery, are needed to understand the impact of checklists in neurosurgery.
Meeting/Conference Proceedings
Agency for Healthcare Research and Quality. October 30, 2019.
This webinar recording provides information on the updated Hospital Survey on Patient Safety Culture™ (SOPS™) 2.0. The hospital survey was revised and pilot tested after incorporating user feedback. The Hospital SOPS survey, which has been used by hundreds of hospitals in the U.S. and overseas, allows healthcare providers and staff to assess a hospital’s patient safety culture. Speakers at the webinar discussed what’s different and what to expect when transitioning to the revised survey. Access the SOPS Hospital Survey 2.0, including a user’s guide, as well as results from a 2019 Pilot Test of Version 2.0 and frequently asked questions.
Special or Theme Issue
Emerging Classic
Health Informatics J. 2020;26:181-189;576-591;683-718;1017-1042;2295-2299;3123-3162.
This special collection examines the use of novel health information technology (HIT) to promote patient safety and challenges in examining the impact of those technologies. Articles featured in this issue include a focus on qualitative approaches to evaluating the impact of HIT on patient safety, particularly through a sociotechnical lens.
HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics. Washington DC: US Department of Health and Human Services. October 2019.
Deprescribing has the potential to result in patient harm. This publication reviews considerations for physicians to safely discontinue or taper long-term opiate therapy. Elements of the guidance discuss assessment of risk, individualized care plans, shared decision making, and patient support as components of safe practice.
Multi-use Website
National Quality Forum.
Maternal safety is a growing concern for the patient safety community. This initiative worked with a multidisciplinary panel to develop measures that identify and track factors that contribute to material morbidity and mortality. A set of recommendations drawn from that work provide a framework to generate improvement. The project concluded in 2021.
Rockville, MD: Agency for Healthcare Research and Quality; September 28, 2022. PA-20-028.
Medication errors are a consistent challenge in health care. This funding announcement seeks applications that focus on standardization and process enhancements to reduce care delivery factors that decrease the safety of medication use. This funding announcement expired January 27, 2022.
Newspaper/Magazine Article
Healy J, Farr I, Feiger L, Duffy C. New York Times. October 11, 2019.
Systemic failures persistently undermine processes meant to keep patients safe. This news story discusses a case involving unexplained patient deaths under the care of one physician and how protections such as automated medicine cabinet overrides, practice audits and reporting and feedback mechanisms were not adequately used to surface criminal behavior.
Newspaper/Magazine Article
Palmer J. Patient Saf Qual Healthcare. Sept/Oct 2019.
The pace of emergency care delivery can reduce reliability. This news story discusses an analysis of medical liability claims over a 5-year period that found diagnostic failure to be the driver of over 50% of the emergency department claims reviewed.
Multi-use Website
Massachusetts Sepsis Consortium.
Delayed diagnosis of sepsis is a primary patient safety concern. This campaign raises awareness of the symptoms of sepsis to engage patients in timely diagnosis and safe treatment of the condition.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute Care Edition. October 10, 2019;24.
The bundling of factors that influence the willingness of health care professionals to raise patient safety concerns is a complex component of organizational culture. This newsletter article highlights the characteristics and subsequent actions of individuals that enable patient safety risks to be identified and reliably acted upon to manage risk.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Adam Wright, PhD, and Gordon Schiff, MD |
Following resection of colorectal cancer, a hospitalized elderly man experienced a pulmonary embolism, which was treated with rivaroxaban. Upon discharge home, he received two separate prescriptions for rivaroxaban (per protocol): one for 15 mg twice daily for 10 days, and then 20 mg daily after that. Ten days later, the patient's wife returned to the pharmacy requesting a refill. On re-reviewing the medications with her, the pharmacist discovered the patient had been taking both prescriptions (a total daily dose of 50 mg daily). This overdose placed him at very high risk for bleeding complications.
WebM&M Cases
Katie Raffel, MD |
An intern night float, called in on jeopardy from an outside institution for an intern who was ill, was paged to the bedside of an unstable patient to assess his condition. In the electronic health record, the intern checked the code status and clinical information, but the signout did not specify the patient’s goals of care nor what course of action to take should the patient worsen. Although the patient was listed as full code and the intern attempted to reach both the rapid response team and the senior resident, she was not aware the pager numbers were incorrect. Eventually, the intern flagged a senior resident passing in the hallway, who assessed the patient and suggested they contact his family.
WebM&M Cases
Christopher F. Janowak, MD, FACS, and Lauren M. Janowak, RN, BSN, CCRN |
Two patients arrived at the Emergency Department (ED) at the same time with major trauma. Both patients were unidentified and were given "Doe" names. Patient 1 was quickly sent to the operating room (OR) but the ED nurse incorrectly gave him Patient 2's "Doe" name. The OR nurse only realized there was a problem when blood arrived with Patient 1's correct "Doe" name, requiring multiple phone calls with the ED, laboratory, and surgeon to correctly identify the patient.
This Month’s Perspectives
Interview
Dr. Chopra is Chief of the Division of Hospital Medicine and Associate Professor of Medicine at the University of Michigan Medical School. His research focuses on improving the safety of hospitalized patients by preventing hospital-acquired complications—particularly those associated with peripherally inserted central catheters.
Interview
Dr. Shah is an Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School and Director of the Delivery Decisions Initiative at Harvard's Ariadne Labs. He is also the founder of the organization Costs of Care. We spoke with him about patient safety in obstetrics, maternal mortality, the importance of dignity, and the overuse of cesarean deliveries.
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