Email Updates
March 4, 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.
Hartvigson PE, Gensheimer MF, Spady PK, et al. Pract Radiat Oncol. 2019.
Trigger tools are used to detect adverse events; their use has been studied in general oncology patients but not in radiation oncology. In this study, researchers developed an automated radiation oncology-specific trigger tool and found that the tool showed modest sensitivity and specificity at identifying treatment courses with serious or critical near misses.
Glauser G, Goodrich S, McClintock SD, et al. J Thorac Cardiovasc Surg. 2021;162:155-164.e2.
Surgical overlap is a longstanding practice, and reports suggest a link to postoperative complications and patient safety. This study measured the impact of overlap on patient outcomes among patients undergoing cardiac surgical interventions over a two-year period and found that overlap did not predict mortality, readmission, reoperation or emergency department visits at 30- or 90-days post-discharge, compared to patients without surgical overlap.
Kim H-E, Kim HH, Han B-K, et al. The Lancet Digital Health. 2020.
There is increasing interest in the use of artificial intelligence (AI) to improve breast cancer detection. This study developed and validated an AI algorithm using mammography readings from five institutions in South Korea, the United States, and the United Kingdom. The AI algorithm alone showed better diagnostic performance in breast cancer detection compared to radiologists without AI assistance (area under the curve [AUC] of 0.94 vs. 0.81, p<0.0001) or radiologists with AI assistance (0.88; p<0.0001). AI improved performance of radiologists and was better at detecting mass cancers, distortion, asymmetry, or node-negative cancers compared with radiologist alone.
Owen-Smith A, Stewart C, Sesay MM, et al. BMC Psych. 2020;20:40.
Prescription opioids are associated with an increased risk of adverse drug events and individual’s underlying mental health conditions may be more likely to be prescribed long-term opioid therapy. This study examined opioid treatment patterns among individuals with schizophrenia, bipolar disorder, or major depressive disorder (MDD) and found that having a diagnosis of bipolar disorder or MDD was associated with increased odds of receiving chronic opioid mediations, whereas a diagnosis of schizophrenia was not.
Frost DA, Snydeman CK, Lantieri MJ, et al. Psychosomatics. 2019;61:154-160.
This study assessed the effectiveness of a suicide prevention checklist in a single hospital developed based on Joint Commission recommendations. In the two years following checklist implementation, suicide attempts decreased by 42% (compared to the preceding two years); the number of patients sustaining temporary or minor injuries also decreased by 57% across the same time period. Survey responses showed that unit nurses felt the checklist list created a safe environment (88%) and that it supported consistent practice (90%) of caring for potentially suicidal patients in nonpsychiatric units.
Dager WE, Ansell J, Barnes GD, et al. Jt Comm J Qual Saf. 2020;46:173-180.
The Joint Commission previously issued a sentinel event alert for medication errors relating to anticoagulant therapies and included them as part of the National Patient Safety Goal (NPSG) program. This commentary discusses the eight 2019 NPSGs for anticoagulants: dosing protocols; anticoagulant reversal; perioperative management; laboratory monitoring; anticoagulant safety; patient education; unit dose packaging, and; programmable pumps.
Pradarelli JC, Yule S, Smink DS. JAMA Surg. 2020;155:438-439.
This article describes an online training module for surgeons to learn and assess nontechnical skills using the Nontechnical Skills for Surgeons (NOTSS) framework (eNOTSS). This platform could support nontechnical skills learning for a global audience. Next steps for platform development and implementation include creating capability for personalized feedback on nontechnical skills and garnering buy-in from health system leadership.
Money NM, Schroeder AR, Quinonez RA, et al. JAMA Pediatr. 2020;174:375-382.
Medical overuse is a well-recognized patient safety challenge. This review expands upon prior research highlighting the top 10 studies published in 2018 that may help reduce overuse in pediatrics. Highlighted articles describe both established practices that may warrant deimplementation (such as routine outpatient opioid prescribing) and emerging practices that merit greater inspection or discouragement from widespread adoption (such as post-discharge nurse-led home visits).
Freeman K, Dinnes J, Chuchu N, et al. BMJ. 2020;368:m127.
Delays in cancer diagnosis can lead to adverse patient outcomes. This systematic review examined whether smartphone-based apps can assist patients in assessing skin cancer risk and whether they should seek medical attention for suspicious lesions. The review included nine studies evaluating six different smartphone apps; reported sensitivity and specificity varied widely across studies. The authors note limitations of the included studies, such as failure to recruit a population representative of the general population. Findings are consistent with earlier studies reporting poor performance of smartphone apps for melanoma detection. Although these apps are intended to reduce delays in diagnosis, the authors conclude they can’t be relied upon for detection of all cases of skin cancer.
Cheraghi-Sohi S, Panagioti M, Daker-White G, et al. Int J Equity Health. 2020;19:26.
To better understand patient safety issues of marginalized groups, this scoping review assessed 67 articles primarily focusing on four patient groups: ethnic minorities, frail elderly, care home residents and those with low socioeconomic status. A variety of patient safety issues were identified, and half of the included studies looked at either medication safety, adverse outcomes, and near misses. This review highlights the need for additional research to understand the intersection between marginalization and the multi-dimensional nature of patient safety issues.
Kuitunen S, Niittynen I, Airaksinen M, et al. J Patient Saf. 2021;17:e1660-e1668.
Intravenous (IV) medication administration errors can cause severe patient harm. In this systematic review, researchers identified eleven studies characterizing the systemic causes of in-hospital IV medication errors. Systemic errors were identified most frequently during medication administration, prescribing and preparation, with common errors involving knowledge gaps, calculation errors, failure to double-check, and confusion between look-alike, sound-alike medications. More research focused on IV medication safety is needed.
Johnson AH, Benham‐Hutchins M. AORN J. 2020;111.
Unprofessional behaviors negatively impact teams and can undermine patient safety. This systematic review examined the influence of bullying on nursing errors across multiple healthcare settings. Fourteen articles were included in the review and four themes were identified: the influence of work environment; individual-level connections between bullying and errors; barriers to teamwork, and; communication impairment. While nurses perceive that bullying influences errors and patient outcomes, the mechanisms are unclear and more research is necessary to determined how bullying impacts nursing practice error.
Helou MA, DiazGranados D, Ryan MS, et al. Acad Med. 2020;95:157-165.
In this scoping review, the authors sought to explore uncertainty in decision making across medical disciplines in order to formulate a model describing the decision-making process under uncertain conditions. After applying a qualitative thematic analysis to the 19 identified articles, six themes emerged: recognition of uncertainty; classification of uncertainty; stakeholder perspectives; knowledge acquisition; decision-making approach and; evaluation of the decision-making process. The proposed framework includes four of these themes as strategies to reduce uncertainty and guide evaluation in order to guide medical decision during uncertain situations, such as diagnosis or when choosing between treatment options.
United States Meeting/Conference
Institute for Healthcare Improvement. Orlando FL, May 14-16, 2024.
This annual conference will host pre-session workshops, panels, and presentations covering a variety of patient safety topics that align with the national agenda for patient safety improvement such as learning systems and leadership, with diagnostic excellence as an additional area of emphasis. The event will feature Dr. Kaveh Shojania as a keynote speaker.
Meeting/Conference Proceedings
Institute for Healthcare Improvement. March 10. 2020.
The measurement of patient safety is a persistent challenge across the health care continuum. This webinar summarizes a set of 8 foundations to guide patient safety measurement improvement that include capitalizing data in real time and engaging patients in the measurement process. Speakers included Dr. Donald Berwick and Helen Haskell.
Newspaper/Magazine Article
Jena AB, Olenski AR. New York Times. February 20, 2020.
Unconscious biases affecting health care decisions elevate the potential for harm. This news story discusses how experience and implicit biases can impact physician decision-making. The use of decision support is one strategy highlighted to redirect heuristics and other cognitive biases to minimize their impact on treatment.
Organizational Policy/Guidelines
Institute for Safe Medication Practices. Horsham, PA: Institute for Safe Medication Practices; 2020.
Smart pumps are widely available as a medication safety tool yet there are challenges affecting their reliable use. This guideline expands on earlier recommendations to support smart pump use in both hospitals and the ambulatory setting. The material provides recommendations that address infrastructure, drug libraries, quality improvement data, workflow and electronic health record interoperability concerns.
London, UK: Academy of Medical Royal Colleges; 2020.
A foundational understanding of safety is core to building reliable care processes and teams. This report outlines a curriculum that was developed in response to a national improvement strategy for National Health Service staff. The training program highlights the themes of the systems approach, risk competencies, human factors and safety culture as linking content domains together to develop safe practitioners.
Newspaper/Magazine Article
Clark C. MedPage Today. February 10, 2020.
It is an institutional responsibility to monitor physicians exhibiting performance issues that put patients into unsafe situations. This news story highlights one hospital system’s lack of action and policy adherence that failed to appropriately manage a physician with known substance abuse issues.
Sheridan S, Merryweather P, Rusz D, et al. Washington, DC: National Academy of Medicine; 2020.
Safety initiatives can be enhanced by engaging patients in the development process. This report highlights one project as an example of how to involve patients as partners in diagnostic improvement research projects. The program resulted in a curriculum that prepared patients to participate as team members in diagnostic improvement studies.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
David Barnes, MD, FACEP and Rita Chang, MD |
A 46-year-old woman presented to the emergency department (ED) triage with a history of a stroke, methamphetamine use, and remote endovascular repair of a thoracic aortic dissection. Her chief complaint was abdominal pain and vomiting and she was assigned Emergency Severity Index (ESI) category 2; however, there were no available beds, so the patient remained in the waiting room. Several hours later, she began to scream in pain on the waiting room floor, was quickly assessed as needing surgery; however, surgery was delayed, and the patient died in the ED.
WebM&M Cases
Christopher Chen, MD and Sandhya Venugopal, MD, MS-HPEd |
The patient safety committee at a large tertiary care hospital received nine incident reports within three months involving electrocardiogram (EKG) reports that were uploaded into the wrong patients’ chart. All of these events were due to users failing to clear the previous patient’s information from, and/or users failing to enter the new patient’s information into, the EKG machine when obtaining an EKG.
WebM&M Cases
Christian Bohringer, MD |
Two patients admitted for deceased donor renal transplant surgery experienced similar near miss errors involving 1000 ml normal saline bags with 160mg gentamicin intended as bladder irrigation but mistakenly found spiked or next to the patient’s intravenous (IV) line. Confusion about using this nephrotoxic drug intravenously could result in significant harm to patients undergoing renal transplant surgery.
This Month’s Perspectives
Interview
Ann D. Gaffey, RN, MSN, CPHRM, DFASHRM is the President of Healthcare Risk and Safety Strategies, LLC. Bruce Spurlock, MD is the President and CEO of Cynosure Health. We spoke with them about their role in the development of the Making Healthcare Safer III Report and what new information they think audiences will find particularly useful and interesting.
Annual Perspective
This piece describes key themes reflected in AHRQ PSNet resources released in 2019 related to how medical, nursing, and other clinical education can better incorporate patient safety concepts.
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