Email Updates
December 11, 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.
Herzberg S, Hansen M, Schoonover A, et al. BMJ Open. 2019;9:e025314.
Many patient safety strategies focus on effective teamwork among healthcare professionals. This study used a validated instrument, the Clinical Teamwork Scale (CTS), to measure overall teamwork in 44 teams of emergency medical services (EMS) professionals as they responded to 176 simulations of pediatric emergencies. Results indicated that fewer errors were made by teams with higher (better) CTS scores.
Leamy K, Thompson J, Mitra B. Australas Emerg Care. 2019;22:221-226.
This article reports the results of a prospective pre-post interventional study undertaken to determine whether providing a simplified information card to patients (in addition to discharge summaries) upon discharge from Australian emergency departments would improve patient awareness of their diagnosis and follow-up requirements. Brief interviews conducted with 112 pre-intervention study participants and 117 who received the short discharge card, indicated statistically significant improvement (73.2% to 89.7%, p<0.001) in patient awareness with the short discharge card.
Zapata JFO. Emerg Radiol. 2019;26:593-600.
Delayed communication of critical radiological findings delays treatment initiation, can result in patient death, and constitutes a major source of medical malpractice litigation. This article documents the impact of an educational intervention aimed at reducing the time taken to inform patients of critical radiological findings. Statistically significant improvements in notification times were observed for both emergency and hospitalized patients after the intervention.
Stocks SJ, Alam R, Bowie P, et al. J Patient Saf. 2019;15:334-342.
"Never events" are serious but generally preventable patient safety incidents. This study surveyed general practitioners in the UK to assess the incidence of specific never-events in those practices, and whether practitioners agreed with the specific events being designated as a never-event. The most commonly reported events were not investigating abnormal test results (45% of practices) and prescribing despite documented adverse reactions (65% of practices); however, these events were also less likely to be designated "never events" by respondents.
Commentary
Allhoff F. Kennedy Inst Ethics J. 2019;29:187-203.
Medical error is an important problem but there has been little examination of associated conceptual and normative aspects. This article explores the association between medical errors and adverse events, challenges current ideas about what comprises a medical error, and considers the concept of moral luck in the context of medical errors. The author introduces a noteworthy argument related to the differences in how we think of undertesting and overtesting and, by extension, underdiagnosis and overdiagnosis.
Graham C, Reid S, Lord TC, et al. Br Dent J. 2019;226:32-38.
Reporting and avoidance of “never events,” such as a wrong tooth extraction, is important for providing consistently safe dental care. This article describes changes made in safety procedures, including introducing surgical safety briefings or huddles in an outpatient oral surgery unit of the United Kingdom’s National Health Service, that eliminated never events for more than two years.
Pereira-Lima K, Mata DA, Loureiro SR, et al. JAMA Netw Open. 2019;2:e1916097.
This systematic review and meta-analysis of 11 studies with a valid measure of physician (n=21,517) depressive symptoms found that physicians who screened positive for depression were associated with medical errors. The authors also conducted a meta-analysis of 7 longitudinal studies, which revealed there was a bidirectional association between physician symptoms of depression and medical errors. This finding implies that physicians that screen positive for depressive symptoms have a higher risk for medical errors. The authors recommend that future studies need to focus on whether interventions to reduce physician depressive symptoms could play a role in reducing medical errors and improving safe patient care.
Li R, Zaidi STR, Chen T, et al. Pharmacoepidemiol Drug Saf. 2020;29:1-8.
Underreporting of adverse drug reactions (ADRs) is an international patient safety problem. This systematic review of studies assessed how various strategies designed to improve ADR reporting impacted ADR rates. While all strategies increased ADR reporting, particularly those using electronic reporting tools, the quality of the studies was generally low. The authors expressed the need for higher quality studies to focus on how electronic methods might improve ADR reporting.
Alghamdi AA, Keers RN, Sutherland A, et al. Drug Saf. 2019;42:1423-1436.
The prevalence and nature of medication errors and preventable adverse drug events in pediatric and neonatal intensive care units were examined in this systematic review. In the 35 quantitative studies included in the review, prescribing and medication administration errors were the most common errors reported, with dosing errors the most frequent subtype, in both types of critical care units. The authors concluded that critically ill children admitted to intensive care units frequently experience medication errors and identified important targets to guide remediation efforts.
No results.
Newspaper/Magazine Article
Gilbert D, Gutman D. Before mea culpa, Children’s was confident its air systems weren’t source of infection. Seattle Times. Nov. 26, 2019.
Problems in the physical environment can contribute to patient harm. This news story discusses systemic failures associated with patient deaths acerbated by a common mold in a hospital heating and cooling system. The actions the organization took to manage the situation are shared; however, the mold wasn't eradicated.
Washington DC; National Quality Forum: October 28, 2019.
Efforts to track, understand and measure diagnostic errors offer continuing challenges to designing improvements. This report updates an earlier environmental assessment on the validity and quality of diagnostic error measures. It identified new types of active measures and related concepts present in the evidence base. The authors also identified advancing the science of diagnostic error as an emerging area of focus.
Chassin M, Foster N. Chicago, IL: American Hospital Association; November 13, 2019.
To Err is Human launched the modern patient safety movement. In this podcast, Dr. Mark Chassin reflects on changes since the report was released and the changes in health care in its wake.
Agency for Healthcare Research and Quality. 2019.
Structured processes are important strategies for embedding safe care practices. This tool kit shares training modules and tools to support a 4-point practice to improve antibiotic prescribing and reduce hospital-acquired infections. Elements of the process center on diagnosis, testing, reassessment and duration.
Newspaper/Magazine Article
Glicksman E. Washington Post. November 17, 2019.
Unconscious assumptions and biases are known contributors to poor decision-making. This news story discusses racial and gender bias as common factors that reduce the accuracy and effectiveness of the diagnostic process.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Karl Steinberg, MD, CMD, HMDC and Thaddeus Mason Pope, JD, PhD |
A 63-year-old woman with hematemesis was admitted by a 2nd year medical resident for an endoscopy. The resident did not spend adequate time discussing her code status and subsequently, made a series of errors that failed to honor the patient’s preferences and could have resulted in an adverse outcome for this relatively healthy woman.
WebM&M Cases
Adrianne M Widaman, PhD, RD |
A 62-year-old man with a history of malnutrition-related encephalopathy was admitted for possible aspiration pneumonia complicated by empyema and coagulopathy. During the hospitalization, he was uncooperative and exhibited signs of delirium. For a variety of reasons, he spent two weeks in the hospital with minimal oral intake and without receiving most of his oral medications, putting him at risk for complications and adverse outcomes.
WebM&M Cases
Erika Cutler, PharmD, and Delani Gunawardena, MD |
A 55-year-old man visited his oncologist for a follow-up appointment after completing chemotherapy and reported feeling well with his abdominal and bony pain well controlled with opioid therapy. At the end of the visit, his oncologist reordered his pain medication and, due to a best practice alert, also prescribed naloxone but failed to provide any instruction on its use. Later that day, the patient took the naloxone along with his opioid pain medication and within a minute experienced severe abdominal and bony pain, requiring admission to the emergency department.
This Month’s Perspectives
Interview
Cindy Brach, MPP is a Senior Healthcare Researcher at the Agency for Healthcare Research and Quality and is the Co-Chair of the HHS Health Literacy Workgroup. We spoke with her about the role of cultural competence in patient safety.
Perspective
This piece describes cultural competence in the context of patient safety and highlights several approaches and projects that may help to improve cultural competence.
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