Email Updates
January 8, 2020 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.
Manges K, Groves PS, Farag A, et al. BMJ Qual Saf. 2020;29:499-508.
Teamwork Shared Mental Models (SMM) reflect the teams’ understanding of its members’ roles and interactions. This mixed-methods study examined teamwork-SMMs during discharge and described the differences of discharge teams with higher versus lower teamwork-SMMs. Teams with better teamwork-SMMs during discharge were more likely to report similar understanding of the patient’s situation, open communication and exchange of information, and team cohesion and resulted in more effective care delivery. Poor team-SMMs were characterized by divergent opinions regarding patient care plans, delays or gaps in communication, and team members operating independently and in isolation from their team.
Ottosen MJ, Engebretson J, Etchegaray J, et al. Adv Neonatal Care. 2019;19:500-508.
Using qualitative methods, this study sought to understand parent perceptions of patient safety in the NICU. The authors present a conceptual model of ‘parents as partners’ in NICU patient safety, emphasizing the importance of clinicians who are present, intentional, and respectful and highlighting factors influencing the parent-clinician partnership, such as communication and teamwork practices.
Carayon P, Hoonakker P, Hundt AS, et al. BMJ Qual Saf. 2020;29:329-340.
This simulation study assessed whether integrating human factors engineering into a clinical decision support system can improve the diagnosis of pulmonary embolism (PE) in the ED. Authors found that this approach can improve the PE diagnostic process by saving time, reducing perceived workload and improving physician satisfaction with the technology.
Scott J, Dawson P, Heavey E, et al. J Patient Saf. 2021;17:e1744-e1758.
This study reviewed incident reports involving older adult patient transitions in geriatrics, cardiology, orthopedics and stroke to identify the types of transitions involved and whether reports included any evidence of individual or organizational learning. Half of all incident reports involved interunit/department/team transfers and the majority (69%) of incidents were related to pressure injuries, falls, medication, and documentation errors. Few incident reports referenced individual or organizational learning (e.g., team discussions, root cause analysis) to inform practice or policy changes. A prior WebM&M describes a medication error occurring during an intrahospital transfer between the ICU and interventional radiology.
Koers L, van Haperen M, Meijer CGF, et al. JAMA Surg. 2019;155:e194704.
Failure to rescue is a significant cause of morbidity and mortality and is often associated with human error. In this innovative study, the authors posit that the use of cognitive aids, which are prompts that can help practitioners’ complete evidence-based tasks (e.g. symptom-specific checklists, flowcharts, and clinical guidelines), could improve timely recognition and effective management of complications in a surgical population. The study randomized surgeons and nurses to manage deteriorating patients in simulated scenarios with or without the use of cognitive aids. Use of cognitive aids significantly reduced omitted critical management steps and failure to adhere to best practices.
Delio J, Catalanotti JS, Marko K, et al. Am J Med Qual. 2020;35:374-379.
Compared to other healthcare workers and hospital employees, physicians have low rates of adverse event (AE) reporting. This intervention integrated mobile AE reporting via text messaging into the daily physician workflow, which resulted in a significant increase in AE reporting, likely due to decreased reporting burden.
Siegal D, Swift J, Forget J, et al. J Healthc Risk Manag. 2020;39:28-36.
This paper describes the experience of one hospital that analyzed its medical malpractice claims to identify practice or policy changes to reduce risk and improve patient safety. Institutional changes in emergency department ultrasound coverage, obstetrics communication, and airway management training are discussed.
Commentary
Khorana MM, Khorana AA. JAMA. 2019;322:2077-2078.
The author tells the story of Matthew, a young man born with Downs syndrome, who began experiencing behavior changes and gastrointestinal symptoms as a teenager. After seven years, visits with multiple clinicians from various specialties, and several prescriptions for high-risk medications, Matthew was ultimately diagnosed with celiac disease by a primary care physician. Unfortunately, diagnostic errors – a common preventable error and threat to patient safety - are not captured through existing quality measures.
Commentary
Emerging Classic
Yorio PL, Edwards J, Hoeneveld D. Safety Sci. 2019;120:402-410.
This paper discusses the relationship between national culture and safety culture, and how national culture influences an individual’s organizational beliefs, assumptions and values related to safety and then how those influence worker perception. The authors provide practical suggestions and directions for future research on organizational patient safety culture.
O’Mahony D. Expert Rev Clin Pharmacol. 2019;13:15-22.
STOPP (Screening Tool of Older Persons' Prescriptions) and START (Screening Tool to Alert to Right Treatment) are criteria used as a tool for clinicians to review potentially inappropriate medications in older adults and have been endorsed as a best practice by some organizations. This article, written by the developer of STOPP/START, describes its history and updates, and current large-scale trials involving the use of specialty software that automates the process as a potential patient safety improvement.
Wu AW, Dzau VJ. Ann Intern Med. 2019;171:933-934.
This commentary discusses how we can apply lessons learned in patient safety to address clinician burnout. Lessons include (1) focusing on systems-level factors, (2) institutional and leadership commitment to change, (3) using measurement for accountability, and (4) directed leadership to implement successful change.
No results.
No results.
Rockville, MD: Agency for Healthcare Research and Quality; December 6, 2019. PA-20-068.
Communication during patient transitions carries the potential for mistakes that can result in patient harm. This program (funding) announcement will support the testing of interventions to improve communication and coordination during care transitions within and between a variety of care environments. Applicants are encouraged to incorporate a care transitions model such as Project RED into their research design. Applications are no longer being excepted.
IHI Lucian Leape Institute. Boston, MA: Institute for Healthcare Improvement, Salzburg Global Seminar; December 2019.
Measurement in patient safety is challenged worldwide by environmental, organizational and patient-focused factors. This report shares 8 principles to guide measurement efforts that result in action. The recommendations include engaging patients as stakeholders, adopting an integrated view of the health care system, and building on safety culture to ensure effective use of the measures to generate improvement.
Special or Theme Issue
Halamek LP, ed. Semin Perinatol. 2019;43(8):151172-151182.
The neonatal intensive care unit (NICU) is a complex environment that serves a vulnerable population at increased risk for harm should errors occur. This special issue draws from a multidisciplinary set of authors to explore patient safety issues arising in the NICU. Included in the issue are articles examining topic such as video assessment, diagnostic error, and human factors engineering in the NICU.
Multi-use Website
New Jersey Hospital Association, the Ohio Hospital Association and The Hospital and Healthsystem Association of Pennsylvania.
Local efforts that draw from the experience of its leaders serve an important role in generating patient safety improvement. This collaboration merges the efforts of three organizations as participants in the federal Partnerships for Patients initiative to engage their constituents in regionally focused safety and quality improvement.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Sarah Barnhard, MD |
A 74-year-old male with a history of hypertension, hyperlipidemia, paroxysmal atrial fibrillation, coronary artery disease, congestive heart failure with an EF of 45%, stage I chronic kidney disease and gout presented for a total hip replacement. He had multiple home medications and was also on Warfarin, which was held appropriately prior to the surgery. A Type and Cross for blood request was sent along with baseline labs; however, there was a mislabeling error on one of the samples causing a delay in the blood getting to the operating room resulting in the medical team initiating a massive transfusion protocol when the patient became hypotensive.
WebM&M Cases
Lamia S. Choudhury, MS1 and Catherine T Vu, MD |
Multiple patients were admitted to a large tertiary hospital within a 4-week period and experienced patient identification errors. These cases highlight important systems issues contributing to this problem and the consequences of incorrect patient identification.
WebM&M Cases
Nasim Wiegley, M.D. and José A. Morfín, M.D. |
A 54-year-old man was found unconscious at home with multiple empty bottles of alcoholic beverages nearby and was brought to the emergency department by his family members. He was confused and severely hyponatremic, so he was admitted to the intensive care unit (ICU). His hospital stay was complicated by an error in the administration of hypertonic saline.
This Month’s Perspectives
Interview
David R. Gruen, MD, MBA, FACR is the Chief Medical Officer, Imaging at IBM Watson Health and is a thought leader and content expert for artificial intelligence in medical imaging. We spoke with him about the role artificial intelligence can play in healthcare diagnostics and the potential for reducing diagnostic errors.
Perspective
This piece discusses the current use of artificial intelligence in diagnostic imaging and key patient safety considerations.
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