Email Updates
March 25, 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.
Hemingway MW, Meleis L, Oliver J, et al. AORN J. 2020;111.
Perioperative personnel often care for patients requiring hazardous drugs, and guidelines recommend specific practices to enhance safe delivery. This article describes a protocol developed by one hospital to minimize healthcare workers exposure to the harmful effects of hazardous drugs (e.g., antineoplastic agents). The protocol includes requirements for personal protective equipment for hazardous drugs, the use of spill kits, and proper storage solutions.
Almalki H, Absi A, Alghamdi A, et al. JAMA Netw Open. 2020;3:e200341.
Effective communication between patients and physicians is essential to ensuring treatment adherence and improved patient outcomes. This cross-sectional study measured agreement in treatment plan understanding between oncology patients and providers in Saudi Arabia and found that most patients (86.2%) had a suboptimal understanding of their chemotherapy treatment plan. Patients commonly did not understand the planned duration of their treatment or the important toxic effects of chemotherapy.
Study
Emerging Classic
Cho K-J, Kwon O, Kwon J-myoung, et al. Crit Care Med. 2020;48:e285-e289.
This study compared an artificial intelligence (AI)-based early warning system using machine learning with conventional trigger methods for predicting deterioration among hospitalized patients, defined as in-hospital cardiac arrest resulting in ICU admissions. The AI system accurately predicted deterioration and was more accurate than conventional methods, demonstrating its potential effectiveness in EHR-based rapid response systems.
Delaloye NJ, Tobler K, OʼNeill T, et al. J Patient Saf. 2020;16.
Simulation training can help interprofessional teams recognize the impact of medical hierarchies on team communication and patient safety. This study evaluated resuscitation team behavior and the influence of perceived authority in response to an incorrect medication order given by a senior physician during a simulated event. Teams exhibited a high rate of deference to the senior physician; half of the teams participating in the simulation followed the incorrect order, 23% followed the order with no attempt to challenge or verify instructions. This study highlights a need for healthcare institutions and providers to be trained on the influence of perceived authority and potential impacts on patient safety.
Todd SE, Thompson AJ, Russell WS. Pediatr Emerg Care. 2020:Epub Jan 21.
This study characterized dose errors on medication orders bypassing pharmacist review in a pediatric emergency department. Over 46,000 medication orders were placed in a 12-month period: of those, 32,000 bypassed pharmacist review through an auto verify function in the EHR. A small proportion (<1%) of these orders were deemed potentially erroneous; most were wrong doses (90%) and the rest were the wrong formulation or given to the wrong patient. None of the potential errors resulted in identifiable patient harm.
Soncrant C, Mills PD, Neily J, et al. J Patient Saf. 2020;16:41-46.
In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.
Dai T, Singh S. Market Sci. 2020;39:540-563.
This paper explores limitations of diagnostic ability, situations in which a diagnostic expert may forego necessary diagnostic tests, and barriers and incentives to diagnostic testing. The authors also discuss the barriers to adopting AI tools intended to enhance diagnostic decision making.
Shojania KG, Marang-van de Mheen PJ. BMJ Qual Saf. 2020;29.
This commentary discusses the two ‘gold standard’ research methods used to identify adverse events– retrospective record review and prospective surveillance using triggers. The authors note that these approaches have served to demonstrate the scope of the patient safety problem and to engage clinicians, managers, researchers and policy makers. However, looking forward, they advocate moving away from the imperfect gold standard of adverse event rates and embracing more specific measures of important safety problems.
Organizational Policy/Guidelines
Farooqi OA, Bruhn WE, Lecholop MK, et al. Int J Oral Maxillofac Surg. 2020;49:397-402.
The over-prescribing of opioids is a recognized contributor to patient harm. This multidisciplinary panel developed six recommendations to manage pain after dental procedures while reducing harm to patients:
(1) Offer alternatives to opioids after dental surgery to interested patients when clinically appropriate.
(2) Avoid prescribing opioids after dental surgery if pain is comfortably management with over-the-counter medication.
(3) Advise patients about non-pharmacological therapies (e.g., cold, heat, distraction).
(4) Teach patients to maximize non-narcotic (over the counter) pain medication with scheduled dosing unless contraindicated.
(5) Engage in shared decision-making with patients.
(6) Consider factors such as medical contraindications, risk for addiction, and risk aversion when prescribing opioids.
Commentary
Coiera E. Lancet. 2020;395:463-466.
This article discusses the influence of artificial intelligence tools and cyber-social systems on human decisions in healthcare. Opportunities to use cyber-social systems in public and population health (e.g., disease tracking) and primary care (e.g., patient-facing technologies, such as symptom checkers) as well as approaches to exploit cyber-social systems within a learning health system are discussed.
No results.
No results.
Newspaper/Magazine Article
Klowak M. CBC News. March 9, 2020.
System weaknesses are often at the root of never events. This news story discusses the suicide of a concussed woman whose care failed due to gaps in team communication, discharge and transition practices.
Newspaper/Magazine Article
Goldstein J, Salcedo A. New York Times. 2020;March 10.
Conditions new to physicians can be difficult to diagnosis. This news story illustrates how heuristics or lack of awareness of emergent and unique diseases can contribute to transmission of infection.
Government Resource
SB 3380. 116th Congress (2020).
This bill submits amendments to existing US federal law to strengthen state-organized efforts to improve health care-associated infection control efforts, pediatric safety initiatives, care transitions, reporting systems and antimicrobial stewardship programs.
Book/Report
Patient Safety Standing Committee. February 6, 2020. Washington DC; National Quality Forum. February 2020.
The development of effective measures to document and track patient safety is challenging. This report contributes to a long-standing initiative to define an evolving set of measures to respond to changes in core areas of focus in the field which include hospital-acquired infections and antibioticuse.
Constellation, Society to Improve Diagnosis in Medicine.
The processes supporting safe and accurate diagnosis involve many steps that are prone to human error. This collaborative will engage teams to explore test result management and follow-up coordination to improve timeliness, collaboration, and communication to support safe care. The launch of the collaborative has been delayed due to COVID-19.
Bennett S. Springer International Publishing; 2020.
Despite efforts to protect patients, harm still occurs during the course of medical care. This book chapter highlights how proactive risk mitigation can reduce opportunities for preventable patient harm. The author reviews tools to reduce the potential for failure used by commercial aviation and how they could be used in health care.
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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