Email Updates
January 29, 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.
Koller D, Binder MJ, Alexander S, et al. J Ped Nurs. 2019;49:1-9.
Research has demonstrated gaps between pediatric patient, parent and physician preferences around disclosure of medical errors. This study enrolled chronically-ill pediatric patients (ages 8-18 years) and used qualitative approaches to explore their views on error disclosure. Participating children expressed strong preferences for error disclosure, apologies, genuine remorse and accountability, as well as a desire to be engaged in patient safety.
Study
Emerging Classic
Agarwal S, Bryan JD, Hu HM, et al. JAMA Netw Open. 2019;2:e1918361.
In 2016, the Centers for Disease Control and Prevention (CDC) issued opioid prescribing guidelines that recommended limiting the duration of therapy for acute pain. Research has found that the guidelines have changed opioid prescribing in the emergency department, but less is known about the impact on postoperative opioid prescribing. This study examined the effect of opioid prescribing duration limits in Massachusetts and Connecticut on postoperative prescribing. Dosing duration limits resulted in decreases in postoperative prescription size and days supplied in Massachusetts but not in Connecticut.
Study
Emerging Classic
El Hechi MW, Bohnen JD, Westfal M, et al. J Am Coll Surg. 2019;230:926-933.
This paper describes the implementation of a "second victim" peer-support program in the surgery department at a tertiary care center. The program trained surgical attendings and trainees to provide peer-support for other surgeons involved in major adverse events. After one-year follow-up, 81% of affected surgeons elected to receive peer support. The majority (81%) felt the program had a positive impact on safety culture by providing a confidential, safe, and timely intervention for so-called "second victims". A 2011 Perspective on Safety with Dr. Albert Wu discussed ways that organizations can support "second victims."
Weingart SN, Nelson J, Koethe B, et al. Cancer Med. 2020;9:1462-1472.
Research has found that trigger tools perform poorly in cancer care. This cohort study comprised of adult patients undergoing treatment for breast, colorectal, lung or prostate cancer investigated the feasibility of a cancer-specific claims-based trigger tool to identify patients with potential adverse events. Results found that triggers affected 19% of patients during their initial year in treatment, and that trigger burden varied by disease, stage, and patient demographics. The most prevalent triggers were abnormal lab test results, blood transfusions, orders for non-contrast CT after chest radiation, and hypoxemia.
Pino FA, Weidemann DK, Schroeder LL, et al. Am J Health Syst Pharm. 2019;76:1972-1979.
Heparin – a commonly used anticoagulant – is a high-risk medication and a patient safety risk to both adults and children. This study used a failure mode and effects analysis (FMEA) to prospectively analyze various steps in the preparation, use and disposal of heparin in a pediatric hospital to identify areas of improvement. The FMEA identified 233 potential failures and 737 potential causes of failure. Underlying causes of failure included mathematical errors, EHR challenges, and varying practice and operating procedures (or lack thereof). Countermeasures to address underlying causes are also addressed.
Pacheco TB, Hettinger AZ, Ratwani RM. JAMA. 2019;322:2339-2340.
The authors analyzed national EHR surveillance data to identify whether reported issues with EHR products that meet Federal standards carry patient safety risks in actual use. Examples include not restricting oral liquid medication dosing to milliliters or having inaccurate standard drug names (RxNorm codes). The study found that nearly 42% of EHR products that underwent surveillance in response to a reported issue were confirmed as having a possible patient harm risk.
McKinney SM, Sieniek M, Godbole V, et al. Nature. 2020;577:89-94.
Research has found that artificial intelligence (AI) can improve diagnostic accuracy, but less is known about its performance in clinical settings. To evaluate the performance of AI in identifying breast cancer in a clinical setting, this study deployed AI in a curated, representative data set from the UK (25,856 women) and an enriched dataset from the US (3,097 women), as well as compared the performance of AI to that of six human radiologist readers. They used biopsy-confirmed cancer patients to evaluate AI predictions. The authors reported a reduction in both false positives and false negatives using AI and found that the AI system was more accurate than the radiologists.
Ho S, Stamm R, Hibbs M, et al. Jt Comm J Qual Patient Saf. 2019;45:814-821.
Recent guidelines from the Institute for Safe Medication Practices have warned of the risk of blood-borne disease transmission associated with insulin pen sharing in hospitalized patients and provide recommendations for safe practices. This paper describes the impact on insulin pen sharing after the implementation of safe practice recommendations (e.g., label redesign, patient-specific bar coding on pens) at a quaternary academic medical center. Institutional efforts resulted in a less frequent pen-sharing events and a decrease in latent errors found during medication drawer audits, such as retained pens after discharge and illegible or missing label.
Ree E, Wiig S. Nurs Open. 2020;7:256-264.
Using survey data from home healthcare works in Norway, this study examined the relationship between patient safety culture and transformational leadership, job demands/resources and work engagement. The authors found that transformational leadership, job resources and work engagement were positively correlated with patient safety culture, and that transformational leadership was the strongest predictor for safety culture, which is consistent with prior research.
Rungvivatjarus T, Kuelbs CL, Miller L, et al. Jt Comm J Qual Patient Saf. 2020;46:27-36.
This study describes a multi-disciplinary quality improvement project aimed at increasing the percentage of completed medication reconciliations upon admission. Interventions included EHR workflow redesigns, provider training, and performance data reporting. After seven months, the project resulted in an increase in medication reconciliation at admission, and a higher percentage of medication reconciled across drug classes, including high-alert drugs.
Nowotny BM, Davies-Tuck M, Scott B, et al. BMJ Qual Saf. 2021;30:186-194.
After a cluster of perinatal deaths was identified in 2015, the authors assessed 15-years of routinely collected observational data from 7 different sources (administrative, patient complaint and legal data) preceding the cluster to determine whether the incidents could have been predicted and prevented. The extent of clinical activity along with direct-to-service patient complaints were found to be the more promising for purposes of potential predictive signals. The authors suggest that use of some routinely collected data of these types show promise; however, further work needs to be done on specificity and sensitivity of the data and to gain access to comparator data is needed.
Schall TE, Foster CC, Feudtner C. JAMA Pediatr. 2019;174:7-8.
Parents or caregivers of children with serious medical conditions who reside at home must balance caregiving demands with other competing responsibilities, such as raising other children, working or maintaining a home – often resulting in unsafe workload. This commentary discusses the need for safe work-hour standards for home caregivers to ensure the well-being and safety of both children and caregivers.
No results.
United States Meeting/Conference
Institute for Healthcare Improvement. Boston, MA and online. September 10--October 22, 2024.
Organization executives influence the success of patient safety improvement. This hybrid workshop will highlight how leaders can use assessments, planning, and evidence to improve the safety culture at their organizations.
Ghaferi A. IHPI Brief. December 2019.
Surgical complications can result in unexpected situations requiring immediate action to save patients. This brief summarizes gaps in failure to rescue processes and shares recommendations for health systems, certification programs and professional organizations to motivate improvement.
Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 7, 2020. Report No. 19-00468-67.
Systemic weaknesses challenge safe care in Veterans Affairs health systems facilities. This report analyzed a patient suicide at one medical center and determined contributors to the failure. This report shares recommendations to address deficiencies including improved communication across the care continuum and reliably acting on root cause analysis results.
Newspaper/Magazine Article
Lintern S. The Independent. January 15, 2020.
The Francis report is a primary example of a large-scale examinations of health care system failure. This story highlights that transparency, duty of candor and whistleblowing protections have improved since the report’s release a decade ago but that more work needs to be done to fully embed a culture of safety throughout the United Kingdom National Health Service.
Newspaper/Magazine Article
Weisman R. Boston Globe. January 13, 2020.
Polypharmacy is a known contributor to adverse drug events in older adults. This story discusses strategies such as brown bag reviews and deprescribing to minimize overprescribing that could contribute to harm.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute care edition. January 16, 2020;26(2):1-6.
Medication errors routinely challenge patient safety. This newsletter article analyzes incidents submitted to the Institute for Safe Medication Practices in 2019 and highlights those that are persistent, yet manageable, if known practice and system changes are implemented.
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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