Email Updates
December 4, 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.
Williams S, Fiumara K, Kachalia A, et al. Jt Comm J Qual Saf. 2020;46:44-50.
A lack of closed-loop feedback systems has been identified as one contributor to underreporting of patient safety events. This paper describes one large academic medical center’s implementation of a Feedback to Reporter program in ambulatory care, which aimed to ensure feedback on safety reports is provided to reporting staff by managers. At baseline, 50% of staff who requested feedback ultimately received it; after three years, the rate of feedback to reporters had increased to 90%.
Sheetz KH, Dimick JB, Englesbe MJ, et al. Health Aff (Millwood). 2019;38:1858-1865.
Since 2013, Medicare’s Hospital-Acquired Condition Reduction Program (HACRP) has reduced payments to hospitals with elevated rates of specific outcomes deemed to be preventable sources of harm. To better understand the impact of the HACRP in Michigan, this study used a surgical registry to compare trends in rates of outcomes targeted by the program to concurrent trends for other hospital-acquired conditions, such as postoperative cardiac arrest and postoperative pneumonia. The authors saw an overall decrease in all hospital-acquired conditions over the eight-year study period but did not identify a statistically significant change in the rate of HACRP-targeted versus non-targeted conditions. The authors acknowledge that these findings may not be generalizable nationally because of robust quality improvement efforts already in place in Michigan, such as existence of other quality improvement efforts, such as the AHRQ-recognized Michigan Surgical Quality Collaborative and the Hospital Engagement Network
Eslami K, Aletayeb F, Aletayeb SMH, et al. BMC Pediatr. 2019;19:365.
Medication errors are thought to be common in neonatal intensive care units (NICUs). This study compared the incidence of medication errors occurring in two NICUs over a three-month period. Over the study period, there were an average of 3.38 medication errors per patient and three-quarters of neonates experienced at least one error. Preterm neonates experienced medication errors significantly more often than term neonates. Errors in prescription dosage and administration were the most common errors.
Melton KR, Timmons K, Walsh KE, et al. BMC Medical Inform Decis Mak. 2019;19:213.
Smart pumps have been adopted as one approach to preventing medication errors, but less is known about their use in pediatric populations and contribution to NICU alert fatigue. This study examined NICU smart pump records from 2014 to 2016 and found that pump alerts do not contribute significantly to overall alert burden in the NICU, and alerts tended to cluster around specific patients and medications (such as fentanyl, insulin and vasopressin). The study also identified 160 attempts to exceed the programmed dosing limit; while these represented a small number of violations over the entirety of the study period, the attempts involved high-risk medications (including fentanyl, insulin, and morphine) and doses programmed at 5- to 24-times the maximum dose which could result in significant adverse patient outcomes.
Barbanti-Brodano G, Griffoni C, Halme J, et al. Eur Spine J. 2019.
Checklists are one tool for improving communication and reducing risk of adverse outcomes. The World Health Organization Surgical Safety Checklist has been previously studied in various surgical specialties; this study sought to determine its effectiveness in spinal surgeries. The authors conducted a retrospective analysis comparing the incidence of complications pre-checklist and post-checklist in a single center and found a significant reduction in the overall incidence of complications after the introduction of the checklist.
Aaronson E, Jansson P, Wittbold K, et al. Am J Emerg Med. 2020;38:1584-1587.
This study evaluated the efficacy of reviewing ED return visits that result in an ICU admission to determine if they were associated with deviations in care and to understand the common errors. They found that of patients who were return ED visits and admitted to the ICU, 44% (223 cases) returned for reasons associated with the index visit and, in those, 14% (31 cases) had a deviation in care at the index visit. Implementing a standard diagnostic process of care framework to those 31 cases with a deviation in care, 47.3% had a failure in the initial diagnostic pathway. The authors concluded reviewing 14 day returns with ICU admissions contribute to better understanding of diagnostic and systems errors.
Zenati MA, Kennedy-Metz L, Dias RD. Semin Thorac Cardiovasc Surg. 2019.
Cognitive engineering (CE) in healthcare explores the environmental complexities and physical demands on providers that may contribute to medical errors. This article discusses cognitive engineering strategies that can be applied to cardiothoracic surgery to improve patient safety. Strategies include automated cognition, team performance sensor-based measurement systems and computer vision for team monitoring.
Singh H, Upadhyay DK, Torretti D. Acad Med. 2020;95:1172-1178.
Diagnostic errors have emerged as a patient safety priority in recent years. The authors propose a five-point plan by which healthcare organizations can pursue diagnostic excellence through error reduction, improving diagnostic processes, and effective communication with patients. Recommendations focused on organizational activities to promote a culture of safety, evidence generation and translation, measurement improvement, and use of errors as a learning opportunity.
Bristol AA, Schneider CE, Lin S-Y, et al. J Healthc Qual. 2019.
Care transitions between hospitals and community settings have been identified as a source of negative patient safety outcomes, such as medication errors or other adverse events. This systematic review focused on transitions of care within hospitals (such as within the same unit or between units) and found two studies demonstrating that the risk of adverse events - such as medication errors, infections or falls - increased as patients experienced three or more transfers. A prior PSNet WebM&M also discussed medication errors that can arise during transitions between hospital units.
de Lima A, Osman BM, Shapiro FE. Curr Opin Anaesthesiol. 2019;32.
Office-based anesthesia (OBA) is being performed more commonly internationally. This narrative literature review updates the evidence related to the safety of OBA and makes recommendations for safe practices including; medical directors to be responsible for evidence-based policies, OBA safety and patient checklists emergency procedures, physical setting requirements, pharmacological management, preoperative procedures, airway management and others. The authors identify that lack of consistent regulations and incomplete protocol standardization is problematic.
No results.
Special or Theme Issue
Castellucci M, Meyer H. Modern Healthcare: November 11, 2019;49:18-22;28-30;32-34.
This special segment shares commentaries and online content that summarize growth and lack of progress in various areas of patient safety since To Err is Human was published. Topics covered include the ineffectiveness of current measures and lack of leadership commitment to the issue. Patient stories and organizational efforts to improve safety are covered in the online segments.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute Care Edition. November 7, 2019
The reporting and analysis of incidents involving medication safety represent a cornerstone of patient safety improvement. This article outlines the process one organization has developed to ensure that appropriate investigation and learning result after reports are submitted.
Canadian Institute for Health Information. Ottawa, ON: Canadian Institute for Health Information; 2019.
This fact sheet presents a comparative analysis of 57 health indicators across 12 countries worldwide and gives Canada's current status on a variety of patient safety measures. While Canada showed strengths in reporting and responding to incidents, the data revealed a 14 percent increase in retained foreign objects since the previous analysis.
Newspaper/Magazine Article
The Associated Press. NBC News. November 8, 2019.
Patients at residential care facilities are particularly vulnerable to harm from medication errors. This story highlights a failure that resulted in the misadministration of insulin during a flu vaccination program.
Preseton E. STAT. November 8, 2019.
Maternal harm and morbidity are recognized patient safety concerns. This article highlights tactics to enable feedback on suboptimal care experiences to facilitate improvement and emotional healing for patients.
Journal Article
Denson JL, Knoeckel J, Kjerengtroen S, et al. BMJ Qual Saf. 2019;29:250-259.
Handoffs are a vulnerable time for patients in which inadequate communication between providers can contribute to adverse outcomes; end-of-rotation handoffs have been found to put patients at even greater risk. Standardizing handoffs has been shown to improve patient safety. This single-center pilot study examined the impact of an ICU handoff intervention consisting of an in-person bedside handoff, a checklist, nursing involvement, and an education session. The authors found that the intervention was feasible to implement with high fidelity and did not improve length of stay or mortality.
Paris, France: OECD Publishing: 2019.
This report documents the overall state of health care, based on an international analysis of population health and health system performance data, with specific chapters on prescribing in primary care, patient safety in surgery, and obstetrics. The results identify areas for improvement while outlining areas of concern.
Book/Report
Vincent C, Staines A. Bern, Switzerland: Federal Department of Home Affairs, Federal Office of Public Health; 2019.
Patient safety is a goal for countries worldwide. This report assessed the current state of safety in Switzerland. The review discusses opportunities available to enhance transparency, quality improvement initiatives, implementation capacity and governance.
Newspaper/Magazine Article
Bendix J. Medical Economics. November 10, 2019;96(21):17.
Despite support for physician disclosure of errors to patients, apologizing for them is still controversial. This commentary discusses the current status of acceptance and legal support for apologies, and how to minimize negative impacts resulting from the activity.
Image/Poster
Oakbrook Terrace, IL: Joint Commission: October 2019.
Inpatient suicide is increasing as a safety concern. This case analysis offers two levels of examination of a hypothetical patient suicide: one that outlines points of failure in the patient’s care and the other that shares strategies to prevent the event from occurring.
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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