Email Updates
January 15, 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.
Bonafide CP, Miller JM, Localio AR, et al. JAMA Pediatr. 2019;174:162-169.
Interruptions are common in busy clinical settings but carry patient safety concerns, particularly if they occur during medication administration. This retrospective cohort study examined one hospital’s timestamped telecommunications data to determine the effect of incoming mobile calls or texts on subsequent medication errors (based on barcode alerts) in a pediatric ICU. Medication administration errors were more common when nurses were interrupted by incoming telephone calls (3.7%) compared to when they were uninterrupted (3.1%), and error risk varied by shift, level of experience, nurse to patient ratio, and level of patient care required. Incoming text messages were not associated with medication administration errors; the authors speculate that this may be attributable to the fact that text message alerts do not require immediate response or that nurses have become accustomed to their frequent occurrence.
Myers JS, Lane-Fall MB, Perfetti AR, et al. BMJ Qual Saf. 2020;29:645-654.
This study used a mixed-methods approach to characterize the impact of two academic fellowships in Quality Improvement Patient Safety (QIPS) to both graduates and their respective institutions. Students in these programs reported a positive impact of the fellowship on their careers, with nearly all being involved in QIPS administration, research or education upon graduation. Interviewed mentors also generally thought the fellowships were important and the resulting research had departmental, institutional and even national importance.
Hussain F, Cooper A, Carson-Stevens A, et al. BMC Emerg Med. 2019;19:77.
This retrospective study reviewed incident reports to characterize diagnostic errors occurring in emergency departments in England and Wales. The majority of incidents (86%) were delayed diagnoses; the remainder were wrong diagnoses. The authors identified three themes stemming from human factors that contributed to the diagnostic errors: insufficient assessment (e.g., failure to order imaging or refer patients when indicated), inappropriate response to diagnostic imaging, and failure to order diagnostic imaging. Potential interventions to address these contributors are briefly discussed.
McLeod PL, Cunningham QW, DiazGranados D, et al. Health Care Manag Rev. 2021;46:341-348.
Effective teamwork is critical to ensuring patient safety, particularly in intensive settings such as critical care. This paper describes a “hackathon” – an intensive problem-solving event commonly used in computer science designed to stimulate creative solutions – focused on the challenges encountered by rapid team formation in critical care settings (such as for cardiac resuscitation). Hackathon teams were multidisciplinary, comprised of healthcare professionals and academics with expertise in communications, psychology and organizational sciences. The paper briefly discusses the three solutions proposed, and the impacts of leveraging this approach for solving other problems specific to health care management.
Businger AC, Fuller TE, Schnipper JL, et al. J Am Med Inform Assoc. 2019;27:301-307.
In 2014, the Agency for Healthcare Research and Quality (AHRQ) began funding Patient Safety Learning Laboratories (PSLL) which use collaborative approaches to incorporate digital health tools to improve patient safety. This research paper discusses the experiences of 12 inpatient units at one large tertiary care center after implementation of a PSLL intended to engage patients, families and the care team in identifying, assessing and reducing threats to patient safety in real time through EHR integration.
Gilleland J, Bayfield D, Bayliss A, et al. BMJ Open Qual. 2019;8:e000763.
Early warning systems and trigger tools are frequently used in inpatient settings to identify clinical deterioration and prevent adverse events in pediatric populations, but their use in community settings to improve illness detection and time to treatment is less common. The article discusses a consensus workshop, the goal of which was to develop the “severe illness getting noticed sooner” (SIGNS-for-kids) tool to empower parents and caregivers by identifying specific cues of severe illness in infants and children. The panel, comprised of parents and healthcare experts, identified five cues: (1) behavior, such as reduced interaction or lack of movement, (2) breathing, including noticeable breathing or long pauses between breaths, (3) skin, such as jaundice or blueish skin/tongue, (4) fluids, such as persistent vomiting or lack of urine, and (5) response to rescue treatments, or deterioration despite use of usually effective treatment.
Ferguson BA, Lauriski DR, Huecker M, et al. J Emerg Med. 2020;58:514-519.
Cognitive errors caused by fatigue can impact patient safety. This study used a brief, electronic cognitive assessment tool to determine the effect of shift work on emergency medicine resident’s alertness. The authors found that alertness is lowest at the end of the evening shift (typically ending between 12:00-2:00am) and there is a significant difference in alertness between the start versus end of the night shift. No significant difference was observed in the day or evening shifts.
Thomas JJ, Yaster M, Guffey P. Jt Comm J Qual Patient Saf. 2019;46:118-121.
The Universal Protocol was intended to prevent wrong site, wrong procedure and wrong person surgery; however, these errors persist. In an effort to reduce wrong-patient charting and near-miss events involving anesthesia, this study implemented a digital photograph to the pre-anesthesia checklist to prompt visual inspection of the patient’s facial image and verification of their hospital ID bracelet. After implementation, only one instance of wrong-patient charting was documented; however, baseline data was unavailable and thus, it is unknown whether this intervention reduced mischarting error.
Pugh CM, Law KE, Cohen ER, et al. Am J Surg. 2020;219:214-220.
Using a human factors engineering framework, this study reviewed video of residents performing a simulated hernia repair to identify and characterize errors, error detection and error recovery. The twenty participating residents made 314 errors; the majority were technical errors (63%) and commission errors (69%; defined as failure to perform a surgical step correctly). Nearly half of all errors went undetected by the residents during the procedure, but when errors were detected, the majority were able to be resolved.
Sauro K, Ghali WA, Stelfox HT. BMJ Qual Saf. 2019;29:341-344.
This commentary discusses the challenges associated with detecting and measuring adverse events, the limitations of measurement alone, and the existing methodologies that can be leveraged to improve the accuracy of adverse event detection.
Kukielka E, Gipson KR, Jones R. Patient Saf. 2019;1(2):36–44.
Reliable telemetry monitoring reduces the potential for rare yet catastrophic patient harm. Drawing from 4 years of data submitted to the Patient Safety Authority reporting system, this article documents factors involved in errors related to the use of telemetry which include battery problems, improper alarm use and communication issues. It highlights training and development of procedures and protocols that align with the practice environment as strategies for improvement.
Machen S, Jani Y, Turner S, et al. Int J Health Care Qual. 2019;31:g146-g157.
This scoping review discussed how organizational and professional culture influences medication safety practices. The authors reviewed over 40 articles and identified four themes influencing medication safety: (1) professional identity, (2) fear of litigation/punishment, (3) hierarchy, and (4) pressure to conform.
Meeting/Conference Proceedings
Agency for Healthcare Research and Quality. May 3, 2022.
This webcast provided an overview of AHRQ’s patient safety culture survey focused on nursing homes in support of efforts to measure staff perception of patient safety culture. Webcast speakers discussed an overview of the program, supplemental items, available resources, and highlighted an opportunity to participate in a pilot study using the tool.
International Meeting/Conference
Institute for Healthcare Improvement and British Medical Journal. ExCeL London, London, UK, April 10-12, 2024.
This onsite conference offers an introduction to quality and safety improvement success and challenges drawing from international experiences. Course activities designed for a multidisciplinary audience will cover six streams including patient safety, leadership, and change.
Newspaper/Magazine Article
Quick Safety. December 17, 2019;(52):1-3.
Incomplete or delayed test result communication is a known factor in diagnostic error. This article shares recommendations to enhance handoffs and information sharing amongst care teams and with patients.
Newspaper/Magazine Article
Szabo L. Scientific American and Kaiser Health News. December 24, 2019.
Artificial intelligence (AI) has the potential to improve care but has not yet been reliably developed to support safe care. This news story discusses concerns associated with the AI development and regulation, and outlines safety issues stemming from use of the technology.
MedStar Health National Center for Human Factors in Healthcare.
Electronic health records (EHR) optimize information functions in care environments while paradoxically introducing inefficiencies and opportunities for error due to usability problems. This series of videos draws from usability research to illustrate how ineffective EHR design can reduce the safety and reliability of care processes that rely on these systems.
Rockville, MD: Agency for Healthcare Research and Quality. December 27, 2019. Publication No. NOT-HS-20-004.
This announcement highlights AHRQ continued interest in research regarding the development of an evidence base on the incidence of diagnostic error, its presence in a variety of health care environment and its impact on patient outcomes.
Newspaper/Magazine Article
Human factors expertise in targeted personnel is a noted health care system improvement strategy. This news piece highlights the National Health Service (NHS) effort to require organizations to develop and employ patient safety specialists with distinct human factors and safety science skill sets to embed system improvements in their organizations and throughout the NHS.
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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