Email Updates
February 19, 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.
Keller S, Tschan F, Semmer NK, et al. PLoS One. 2019;14.
In this prospective study, trained observers assessed communication and triggers of tense communication during elective abdominal operations led by 30 different surgeons. Observers identified an average of 1.21 tense episodes per hour. Situational aspects accounted for a majority of tense communications, triggered primarily by coordination and task-related problems. More tension was associated with lower perceived teamwork quality for all team members except the primary surgeons.
Terry D, Kim J-ah, Gilbert J, et al. Int J Health Serv. 2019.
The authors of this paper analyzed survey responses from 304 Australian patients about their perceptions and experiences with medical errors, such as the perceived source of error and error reporting. Survey respondents emphasized the importance of clear, open, and reciprocal communication and the need to improve detection, reporting and disclosure of medical errors, adverse events, and near misses.
Walji MF, Yansane A, Hebballi NB, et al. JDR Clin Trans Res. 2020;5:271-277.
Building upon prior research developing trigger tools for identifying preventable errors in dentistry, this study reviewed 1,885 electronic health records (EHR) across four dental practices and found that 16% contained an adverse event. The most common events were pain (27.5%), hard tissue (14.8%) or soft tissue injuries (14.8%) and nerve injuries (13.3%). An EHR-based trigger tool can be an effective approach to identifying safety incidents and measuring the quality of care.
Crannage AJ, Hennessey EK, Challen LM, et al. Ann Pharmacother. 2020;54:561-566.
Pharmacists play an important role in patient safety, particularly bridging transitions of care between inpatient and outpatient settings. This study assessed the impact of a discharge medication education program for high-risk patients, including scheduling a post-hospital discharge telephone follow-up within 2 days of discharge. This intervention increased the number of patients who were successfully contacted post-discharge (from 20% pre-intervention to 78%) and seen in clinic within 14-days (from 49% to 60%) and reduced the 30-day readmission rate (from 19% to 10%).
Christiansen TL, Lipsitz S, Scanlan M, et al. Jt Comm J Qual Patient Saf. 2020.
The Fall TIPS (Tailoring Interventions for Patient Safety) program has been shown to be effective in preventing inpatient falls through formal risk assessment and tailored patient care plans. This study demonstrated that patients with access to the Fall TIPS program are more engaged and feel more confident in their ability to prevent falls than those who were not exposed to the program.
Greene MT, Gilmartin HM, Saint S. Am J Infect Control. 2020;48:2-6.
This cross-sectional study reports the results of an ongoing national survey of infection preventionists to assess hospital infection control program characteristics and organizational practices to prevent common healthcare-associated infections. One-third of responding hospitals reported characteristics of organizational safety culture (e.g. employee perceptions of feeling safe to speak up, ask for help, or provide feedback), which was associated with increased odds of using some recommended practices for preventing catheter-associated urinary tract infections and ventilator-associated pneumonia.
Martin GP, Chew S, Dixon-Woods M. Health (London). 2021;25:757-774.
After findings of gross negligence, the National Health Service (NHS) introduced ‘Freedom to Speak Up Guardians’ to lead safety culture change with the ultimate goal that speaking up about safety issues becomes the norm. The authors used semi-structured interviews with 51 individuals (e.g., Guardians, clinicians, policymakers/regulators, etc.) to describe the rollout of the Guardians. These interviews revealed that the role of the Guardians is rich in potential but that the initial narrow role of addressing only quality and safety concerns was not consistent with the myriad of complex issues brought to them and may indicate the need to expand the role definition.
Quinlivan L, Littlewood DL, Webb RT, et al. J Mental Health. 2020;29:1-5.
This editorial proposes adapting a patient safety paradigm – Safety-I or Safety-II – to provide insights into suicidal behavioral, as it is a preventable outcome and health services play an important role in reducing its incidence. The new paradigm – Safety III – would incorporate on health services research combined with ethnography and strong patient/public involvement.
Commentary
Emerging Classic
Thomas EJ. BMJ Qual Saf. 2019;29:4-6.
Achieving “zero harm” has been advocated as a patient safety goal. This editorial proposes that the conversation shift from striving to achieve absolute safety (Zero Harm) towards actively managing risk using both reactive and proactive approaches to safety management.
Commentary
Blustein J, Wallhagen MI, Weinstein BE, et al. Jt Comm J Qual Patient Saf. 2019;46:53-58.
The authors of this narrative review propose that hearing loss be included in the patient safety conversation, noting that poor hearing has been linked with poor outcomes including higher rates of hospitalization, increased length of stay, and greater likelihood for 30-day hospital readmission. The authors suggest that hearing loss be a priority item on safety agendas put forward by organizations such as The Joint Commission.
Review
Emerging Classic
Mello MM, Frakes MD, Blumenkranz E, et al. JAMA. 2020;323:352-366.
This systematic review synthesized evidence from 37 studies to examine the association between malpractice liability risk and healthcare quality and safety. The review found no evidence of association between liability risk and avoidable hospitalizations or readmissions, and limited evidence supporting an association between risk and mortality (5/20 studies) or patient safety indicators or postoperative complications (2/6 studies).
DeAntonio JH, Leichtle SW, Hobgood S, et al. J Surg Res. 2019;246:482-489.
Trauma patients are particularly vulnerable to medication errors due to the severity of their injuries and the multiple handoffs and transitions often occurring during their hospital stay. This article reviewed existing medication reconciliation strategies and found that many have poor accuracy, can be costly and time-consuming, and may not be applicable to a trauma population. The authors comment on the urgent need for research supporting safe and efficient medication reconciliation in trauma patients.
Huff C. Clin J Oncol Nurs. 2020;24:22-30.
Prior studies have identified medication errors associated with oral chemotherapy. This article discusses the evidence establishing a foundation for standardizing oral chemotherapy safe-handling education for healthcare providers, patients and caregivers. The authors provide an overview of a safe-handling checklist they developed, which consists of 12 educational components that clinicians or homecare nurses can use to facilitate patient and caregiver education.
Carayon P, Wooldridge AR, Hoonakker P, et al. App Ergon. 2020;84:103033.
This narrative review describes the Systems Engineering Initiative for Patient Safety (SEIPS) and SEIPS 2.0 models, which provide a framework for integrating human factors and ergonomics into healthcare quality and patient safety improvements. The authors propose a SEIPS 3.0 model which would include the patient journey, defined by the authors as “the spatio-temporal distribution of patients interactions with multiple care settings over time.”
United States Meeting/Conference
Institute for Healthcare Improvement. September 10-17, 2024.
Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.
Cousins D. Croydon, UK: Accidents against Medical Accidents; 2020.
Health care organizations can learn from internal and external incidents to identify potential patient safety risks and incorporate care process improvements. This report suggests that England’s National Health Service has yet to build accountability and reliability into its response to practice alerts. The authors share 4 primary concerns and recommendations to address the alert compliance gaps that focus on clarity on action expected, transparency, communication and monitoring.
Newspaper/Magazine Article
Gabler E. New York Times. January 31, 2020.
Pharmacists are instrumental to safe medication use in the ambulatory setting. This news story discusses factors in retail pharmacy environment that degrade pharmacists’ ability to safely practice, which include production pressure, required multitasking, and distraction. Strategies highlighted to mitigate the problem that have been inconsistently applied include scheduled breaks and staff supervision limits.
Newspaper/Magazine Article
Rau J. Kaiser Health News. January 30, 2020.
Medicare reimbursement restrictions are a controversial stimulus to motivate hospital acquired condition reduction efforts. This news article examines the legacy of the penalties, the data's ability to be effectively applied across various types of institutions, and the lack of direct connection to improvements.
James G. House Commons Report 31. Department of Health and Social Care. London, England: Crown Copyright; 2020. ISBN 9781528617284.
Sharing information from large-scale failure investigations provides insights on latent factors that contribute to patient harm. This analysis discusses a criminal case involving one surgeon in the National Health Service. The examination uncovered problems perpetuated by culture, lack of respect for patient concerns, poor complaint follow-up and organizational blindness. The report summarizes recommendations to reduce similar situations through improving patient communication, organizational accountability and complaints management.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Monica Donnelley, PharmD, Thomas Joseph Gintjee, PharmD, and James Go, PharmD |
This commentary involves two patients who were discharged from the hospital to skilled nursing facilities on long-term antibiotics. In both cases, there were multiple errors in the follow up management of the antibiotics and associated laboratory tests. This case explores the errors and offers discussion regarding the integration of a specialized Outpatient Parenteral Antimicrobial Therapy (OPAT) team and others who can mitigate the risks and improve patient care.
WebM&M Cases
Garth H. Utter, MD, MSc and David T. Cooke, MD |
A man with mixed connective tissue disease on low-dose prednisone and methotrexate presented in very poor condition with chest and left shoulder pain, a left hydropneumothorax, and progressive respiratory failure. After several days of antibiotic therapy for a community-acquired pneumonia (CAP), it was discovered he had esophageal perforation.
WebM&M Cases
Nam K Tran, PhD, HCLD (ABB), FAACC and Ying Liu, MD |
This commentary involves two separate patients; one with a missing lab specimen and one with a mislabeled specimen. Both cases are representative of the challenges in obtaining and appropriately tracking lab specimens and the potential harms to patients. The commentary describes best practices in managing lab specimens.
This Month’s Perspectives
Annual Perspective
This perspective describes key themes reflected in AHRQ PSNet resources released in 2019 related to patient safety in primary care.
Annual Perspective
This perspective describes key themes reflected in AHRQ PSNet resources released in 2019 related to how the use of HIT can improve patient safety.
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