Email Updates
November 6, 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.
Ganguli I, Simpkin AL, Lupo C, et al. JAMA Netw Open. 2019;2:e1913325.
Cascades of care (or follow up) on incidental findings from diagnostic tests are common but are not always clinically meaningful. This study reports the results of a nationally representative group of physicians who were surveyed on their experiences with cascades. Almost all respondents had experienced cascades and many reported harms to patients and personal frustration and anxiety that may contribute to physician burnout.
Rhudy LM, Johnson MR, Krecke CA, et al. Worldviews Evid Based Nurs. 2019;16:362-370.
Nursing handoffs at change of shift are critical for nurses to exchange information about patients; disruptions have been associated with adverse events. After observing 100 nurse-to-nurse handoffs and conducting four focus groups, authors identified multiple sources of disruptions including those by patients and family members, which accounted for half the interruptions outside of the nurse handoff dyad. Nurses identified some interruptions as valuable and relevant to patient care.
Cullen SW, Xie M, Vermeulen JM, et al. Med Care. 2019;57:913-920.
Various factors can impact patient safety risk in psychiatric settings. This study assessed the prevalence of AEs and MEs in community hospitals and Veterans Health Administration (VHA) hospitals and found that psychiatric inpatients at community hospitals were twice as likely to experience these patient safety events than VHA inpatients, even after controlling for patient and hospital characteristics.
O'Reilly-Shah VN, Melanson VG, Sullivan CL, et al. BMC Anesthesiol. 2019;19:182.
Utilizing American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) data, the authors looked at the effects of intraoperative handoffs involving anesthesia personnel in two hospitals. Initial findings of higher rates of adverse outcomes were no longer statistically significant when confounding variables were added to the analysis.
Hazen ACM, Zwart DLM, Poldervaart JM, et al. Fam Pract. 2019;36:544-551.
This cross-sectional study examined how and to what extent non-dispensing pharmacists embedded in a general practice reported solving medication problems through clinical medication reviews in an elderly cohort of patients. The reviews identified 1,292 drug therapy problems, citing overtreatment most frequently (24%) followed by undertreatment (21%) errors. Integrating non-dispensing pharmacists into general practice may help identify and solve drug therapy problems in the elderly in this setting.
Abdallah W, Johnson C, Nitzl C, et al. J Health Organ Manag. 2019;33:695-713.
Organizations are encouraged to learn from failure. The authors surveyed hospital pharmacists to explore how organizational learnings relates to safety culture and found that the strongest contributors to safety culture were organizations prioritizing and supporting training and education.
Ebbens MM, Errami H, Moes DJAR, et al. Eur J Intern Med. 2019;70:50-53.
Patients are at risk for medication errors during transitions of care, which can result in patient harm. This study sought to identify risk factors for error in nephrology patients in the ambulatory care setting. Authors found that 68% of patients experienced a medication error and 71% of those were identified as having the potential to cause harm. Higher numbers of medications were also associated with medication errors.
Schwappach DLB, Niederhauser A. Int J Ment Health Nurs. 2019;28:1363-1373.
This study focused on healthcare workers speaking-up behavior in six psychiatric hospitals in Switzerland. The authors found significant differences in speaking-up despite having moderate to high scores on items that were associated with psychological safety. Although nurses reported patient safety concerns more frequently, they also remained silent more often compared with psychologists and physicians, indicating they may feel less psychological safety.
Axtell AL, Moonsamy P, Melnitchouk S, et al. J Thorac Cardiovasc Surg. 2019.
Physician work hours and fatigue can impact patient safety, particularly among subspecialties focused on high-risk patients. This retrospective cohort study examined outcomes of patients undergoing nonemergent cardiac surgery occurring before or after 3pm. The investigators found no differences in mortality, complications, or length of stay and posit that this may stem from resource availability in these specialized care settings regardless of the time of day.
Yeh J, Wilson R, Young L, et al. J Nurs Care Qual. 2019;35:115-122.
Prior research has found that nonactionable alarms are common and contribute to alarm fatigue among providers in intensive care units. This single center study employed an interprofessional team-based approach to adjust the default thresholds for arrhythmias and specific parameters such as oxygen saturation, which resulted in a nearly 47% reduction in nonactionable alarms over a two-week period.
Havaei F, MacPhee M, Dahinten S. J Adv Nurs. 2019;75:2144-2155.
This study looked at the impact of two different models of delivering care by nurses, team versus total care, on quality of care and adverse events. The authors found that the team nursing model reported higher frequency of adverse events when there were licensed practical nurses on the team.
Kennedy AR, Massey LR. Am J Health Syst Pharm. 2019;76:1481-1491.
This Special Feature discusses risks and vulnerabilities around medications in non-pediatric hospitals that provide care to pediatric patients. The authors identify risks and provide recommendations to ensure safe care of children including optimizing technology, utilizing external resources, and ensuring a pediatric pharmacist is in place.
Lemos C de S, Poveda V de B. J Perianesth Nurs. 2019;34:978-998.
This integrative review examined the factors contributing to perioperative adverse events resulting from anesthesia. Researchers found that both active errors, such as medication errors or inattention, and latent errors, such as communication failures, contributed to adverse events.
No results.
Newspaper/Magazine Article
Rabin RC. New York Times. October 14, 2019.
Drug shortages create potential complexities in drug therapy that can result in unsafe medication use. This story examines a vincristine shortage affecting pediatric patients. Systemic factors contributing to the problem discussed include medications produced by a single supplier and workarounds when supplies are threatened.
Silver Spring, MD; US Food and Drug Administration: October 4, 2019.
Medication error is a persistent challenge to safe care. This funding announcement seeks to stimulate research aligned with the FDA’s Safe Use Initiative.
Book/Report
Washington DC: Leapfrog Group; 2019.
Ambulatory surgery centers (ASC) are established venues for surgical care despite engagement in assessment to ensure their safety. This report analyzed a variety of components related to high quality ASC services and found them lacking in appropriately skilled clinical staffs, patient communication processes and safety practice implementation.
Congressional Testimony
US House of Representatives Committee on Veterans Affairs Subcommittee on Oversight and Investigations. 116th Cong, 1st Sess (2019).
The Veterans Affairs (VA) health system is responsible for both systemic achievements and challenges. This hearing examined a series of problems occurring in the VA system including unexplained deaths of patients. Strategies presented during testimony to remedy these situations include improving employee background checks, credentialing gaps and response to reported clinician performance concerns.
Newspaper/Magazine Article
McLean K. Huffington Post. October 16, 2019.
Medical mistakes cause stress for both patients and their clinicians who treat them. This first-person account shares the experience of a gynecologic oncology fellow whose mistake harmed a patient. She discusses the value of an apology both for clinician and patient healing.
Washington DC: Leapfrog Group; 2019.
Ambulatory surgery centers (ASC) are established venues for surgical care despite lack of engagement in assessment to ensure their safety. This report analyzed a variety of components related to high quality ASC services and found them lacking in appropriately skilled clinical staffs, patient communication processes and safety practice implementation.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2019. ISBN: 9780309495509.
Clinician burnout is a known contributor to unsafe care. This report summarizes evidence on the causes and impacts of clinician burnout. The authors share six recommendations for improvement which include redesign of the learning environment, technologies, and support services for clinicians.
Newspaper/Magazine Article
Bailey M. Kaiser Health News. October 17, 2019.
Patient falls with harm are a common sentinel event. This news story discusses the unintended consequences of efforts to avoid system penalties for patient falls which have resulted in patients kept in bed despite value in their appropriate ambulation.
This Month’s WebM&Ms
WebM&M Cases
Sierra Rayne Young, Pharm.D. and Iris Chen, Pharm.D., BCPS |
Three patients were at the same hospital over the course of a few months for vascular access device (VAD) placement and experienced adverse outcomes. The adverse outcomes of two of them were secondary to drugs given for sedation, while the third patient’s situation was somewhat different. Vascular access procedures are extremely common and are relatively short but may require the use of procedural sedation, which is usually very well tolerated but can involve significant risk, as these cases illustrate.
WebM&M Cases
Caitlin E. Kulig, PharmD and Imo A. Ebong, MBBS, MS |
A young woman is admitted with abdominal pain, nausea, and weakness and found to have a urinary tract infection and was started on intravenous levofloxacin. She also received her home medications, which included lithium and an atypical antipsychotic (quetiapine) along with lithium for bipolar disease and multiple doses of intravenous ondansetron and metoclopramide as treatment for nausea. Subsequently, she was observed to be bradycardic with a widening QRS complex on telemetry and became pulseless and unresponsive. Luckily, advanced cardiac life support was implemented with a return of heartbeat and circulation. The use of common medications that caused QT prolongation contributed to this adverse event.
WebM&M Cases
Spotlight Case
Glen Xiong, MD and Debra Kahn, MD |
Two different patients were seen in the emergency department a history of excessive alcohol consumption and suicidal ideation along with other medical comorbidities. In both cases, acute medical conditions prevented a comprehensive psychiatric evaluation being completed by psychiatric emergency services. Unfortunately, both patients were discharged after resolution of their medical conditions and were later found dead.
This Month’s Perspectives
Interview
Dr. Wald, MD, MSPH, is the Chief Quality and Safety Officer at SCL Health in Denver, CO. She has previously served as a physician advisor for the Colorado Hospital Association and as a Quality Committee Chair for the American Geriatrics Society. We spoke with her about patient safety concerns when caring for frail older patients.
Perspective
This piece describes patient safety risks when caring for frail older patients and summarizes potential approaches for clinicians to minimize this risk.
Stay Updated!
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. Sign up today to get weekly and monthly updates via emails!
