Email Updates
May 13, 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.
Hamadi H, Borkar SR, DHA LRM, et al. J Patient Saf. 2021;17:e1814-e1820.
Using data from the American Nursing Credentialing Center Magnet Recognition Program, the CMS Hospital-Acquired Conditions Reduction Program (HACRP), and survey data from the American Hospital Association, this study analyzed the association between hospitals’ nursing excellence accreditation and patient safety. The authors found that Magnet hospitals are more likely to have lower patient safety indicator (PSI) 90 scores but higher catheter-associated urinary tract infection and surgical site infection scores. The authors conclude that while the processes, procedures and educational aspects associated with Magnet recognition seem to improve nursing-sensitive patient safety outcomes, there are still opportunities for improvement.
Farag A, Vogelsmeier A, Knox K, et al. J Gerontol Nurs. 2020;46:21-30.
Using a random sample of 500 nursing home nurses in one state, this study tested a proposed predictive model assessing nurses’ willingness to report medication near-misses. On a scale from 0 to 3 (where high scores indicate more willingness to report) the mean score of nurses’ willingness to report near-miss incidents was 1.79. The model predicted a 19% variance in willingness to report. The strongest predictors of willingness to report were non-punitive safety climate, transformational leadership, trusting relationships with nurse managers, and familiarity with the reporting system. The authors conclude that social and system factors are necessary to improve nurses’ voluntary reporting of medication near-misses.
Weingart SN, Yaghi O, Barnhart L, et al. Appl Clin Inform. 2020;11.
To decrease the risk of diagnostic errors attributed to incomplete recommended diagnostic tests, this study evaluated an electronic monitoring tool alerting clinicians to incomplete imaging tests for their ambulatory patients. Compared to the control group (physicians not receiving alerts for their patients), after 90-days the intervention group had a higher rate of imaging completion (22.1% vs. 18.8%); this difference was sustained throughout the 12-month follow-up period (25.5% completion in the intervention group versus 20.9% in the control group). The authors found that this change was primarily driven by completion rates among patients referred for mammography. To fully appreciate the implications of missed test notifications to reduce the risk of delayed diagnoses, more studies are necessary.
Lagoo J, Berry WR, Henrich N, et al. Jt Comm J Qual Patient Saf. 2020;46:314-320.
As part of a quality improvement initiative to enhance surgical onboarding, the authors used semi-structured interviews with 20 physicians to understand potential areas of risk when a physician begins working in an unfamiliar setting. Qualitative analysis found that three key findings: (1) physicians often receive little to no onboarding when starting to practice in a new setting, which can limit their ability to provide safe care; (2) physicians felt onboarding inadequately fostered strong interpersonal relationships among health care teams, which impedes psychological safety and team cohesion, and; (3) physicians noted an increased risk of patient harm during emergency situations in new settings due to lack of understanding of culture, workflow, roles/responsibilities and available equipment.
Benda NC, Wesley DB, Nare M, et al. J Patient Saf. 2022;18:e1-e9.
To determine whether language barriers contribute to patient safety events, the authors analyzed near-miss and adverse event reports occurring in patients with a preferred language other than English. Of 1,553 included reports, 13% were likely or plausibly related to a patient’s language barrier. The most common strategy for preventing future events cited in these reports involved use of interpreter services.
Abdelhadi N, Drach‐Zahavy A, Srulovici E. J Adv Nurs. 2020;76:2161-2170.
This qualitative study conducted focus groups with 28 registered nurses working in different hospital settings to explore perspectives regarding decision-making and personal or contextual attributes leading to missed nursing care. Three themes emerged based on the analysis: missed nursing care can result due to scarce resources or nurses’ agency, differences in thinking based on routine or novel situations, and situational factors triggering fluctuations in their awareness (such as "difficult" patients or the presence of family). The authors suggest that organizational training programs should encourage nurses to identify barriers and facilitators of missed nursing care and approaches to overcome these factors.
Choi GYS, Wan WTP, Chan AKM, et al. Br J Anaesth. 2020;125:e236-e239.
This study used high-fidelity clinical simulation to replicate admission, including tracheal intubation, of a patient with suspected or known COVID-19 infection to assess the ability of healthcare teams to effectively use personal protective equipment (PPE), the use of intubation protocols and infection control guidelines. Based on observations of 11 simulations involving 44 participants, several infection control-related workflow problems and safety threats were identified, including issues with PPE donning and doffing, advance preparation of intubation and ventilation strategies, environmental protection measures, communication difficulties, and accessibility of key drugs and equipment. These findings resulted in guideline changes, modifications to the environment and implementation of workflow modifications to improve ability of staff to adhere to infection control guidelines.
Zhao Z, Bai H, Duan J, et al. Thorac Cancer. 2020.
The COVID-19 pandemic is negatively impacting patients with non-COVID-related disease and providers are being faced with challenges in delivering ongoing care to patients with chronic health conditions, such as cancer. This article provides recommendations for alternative treatment for lung cancer patients undergoing chemotherapy and other targeted therapies. The authors also suggest approaches to managing treatment-related adverse events outside the hospital to reduce virus exposure among an immunocompromised population.
Leistikow I, Bal RA. BMJ Qual Saf. 2020;29:869–872.
This article discusses how resilience and learning from things that go right (i.e., Safety-II) can influence interactions between healthcare providers and external regulatory systems. The authors present the five core concepts of Safety-II (definition of safety, safety management principles, human factors, accident investigation, and risk assessment) and depict their impact on accountability between healthcare providers and regulators.
Cinar P, Kubal T, Freifeld A, et al. J Natl Compr Canc Netw. 2020;18:504-509.
This article reviews strategies to mitigate transmission of COVID-19 among patients with cancer and for the healthcare workers providing care to those patients. The authors recommend several approaches ensure patient safety, including COVID-19 prescreening/screening via telemedicine, greater utilization of tele-oncology, limiting surgeries and procedures to only essential, urgent, or emergent cases, and switching therapies to oral (versus infusion) when possible. They also propose measures focused on healthcare worker safety, including appropriate use of personal protective equipment (PPE), use of daily screening tools and/or temperature checks, greater use of telework and limited onsite staff, and clear stay-at-home and return-to-work guidelines.
O’Donovan R, McAuliffe E. Int J Qual Health Care. 2020;32:240-250.
This systematic review analyzed 36 articles exploring factors enabling psychological safety in healthcare teams. The review identified five themes of enabling factors: (1) priority for patient safety, such as safety culture or leadership behavior; (2) improvement or learning orientation leading to a culture of continuous improvement or change-oriented leadership; (3) support from peers, leadership or the organization; (4) familiarity between and across teams and with team leaders, and; (5) status, hierarchy and inclusivity. These themes can aid future objective measures of psychological safety and interventions to improve psychological safety within teams.
Nagendran M, Chen Y, Lovejoy CA, et al. BMJ. 2020;368:m689.
This systematic review assessed randomized and non-randomized trials comparing the performance of artificial intelligence (AI; specifically deep learning algorithms) in medical imaging versus expert clinicians in order to characterize the state of the evidence and suggest future research directions which encourage innovation while protecting patients. The review identified 10 registered trials and 81 published non-randomized trials. Although 61 of 81 published studies reported that AI performance was comparable or better than that of clinicians, the authors identified few prospective studies or studies conducted in real-world settings; additionally, overall risk of bias was high and adherence to reporting standards was poor. Future studies examining the impact of AI in medicine must decrease risk of bias, increase relevance to real world clinical settings, and improve reporting and transparency.
Houghton C, Meskell P, Delaney H, et al. Cochrane Database Syst Rev. 2020;4:CD013582.
To support the needs of healthcare workers during the COVID-19 pandemic, this rapid evidence review of qualitative research studies sought to identify barriers and facilitators to healthcare workers adherence to infection prevention and control guidelines for respiratory infectious diseases. The authors included 20 studies in their analysis; these studies explored the views and experiences of nurses, doctors and other healthcare workers working in hospitals, primary care, and community care settings dealing with infectious diseases such as SARS, H1N1, MERS, TB, or seasonal influenza. Identified barriers included local guidelines that were lengthy, ambiguous or not reflective of national or international continuously changing guidelines, lack of support from management to adhere to guidelines, and lack of high-quality personal protective equipment (PPE). Facilitators to guideline adherence included clear communication and training about the infection and use of PPE, sufficient space to isolate patients, workplace safety culture, and perceived value of adhering to infection prevention and control guidelines.
Sinnott C, Georgiadis A, Park J, et al. Ann Fam Med. 2020;18:159-168.
This review synthesized research exploring how operational failures (e.g., distractions, situational constraints) in primary care affect the work of primary care physicians. The literature suggests that operational failures are common, and the gap between what physicians perceive that they should be doing and what they were doing (“work-as-imagined” vs, “work-as-done”) is largely attributed to operational failures over which the primary care physicians had limited control. The authors suggest that future research focus on which operational failures have the highest impact in primary care settings in order to prioritize areas for targeted improvement.
Meeting/Conference Proceedings
COVID-19 Special Series. Institute for Healthcare Improvement.
The rapidly evolving response to the COVID-19 pandemic is enhanced through the sharing of data, information, and knowledge. This series of webinars moderated by Dr. Don Berwick and Derek Feeley, CEO, cover a range of topics to disseminate experience from the field and encourage learning. Topics covered include telemedicine, crisis standards of care, and response implementation.
Multi-use Website
Circle Up for COVID-19 Training. Center for Medical Simulation.
Communication strategies are important for engaging staff in behaviors that support effective teamwork. This website highlights a process that involves briefings, supportive conversations, and debriefings as a communication structure for use during COVID-19 care episodes and other complex interactions.
National Academies of Sciences, Engineering, and Medicine. Washington, DC; The National Academies Press: 2020. ISBN 9780309676250.
Patient safety is challenged during public health emergencies. This report examines a 10-year initiative to develop crisis preparedness standards. The material covers how to proactively apply the program’s experience to assess legal and ethical considerations, learn from federal and state initiatives, address challenges and design steps to continue progress.
Audiovisual Presentation
People’s Pharmacy. Show 1209. April 28, 2020.
Accidental harm to patients is a persistent challenge in health care. This interview features Dr. Danielle Ofri who provides an overview of error in medicine. She draws from both general and COVID-19 pandemic care experiences to illustrate the difficulties involved in measuring, understanding and improving patient safety.
Buckinghamshire, UK. Clinical Human Factors Group. April 2020.
Poor equipment and device choices increase the potential for user errors that contribute to unintended patient harm. Human factors considerations help to identify and avoid risks as part of the equipment and device procurement process. This report guides decision- making in three areas: determining when human factors expertise is required, developing a human factors specification and evaluating potential choices with those specifications in mind. A collection of checklists to guide safe procurement is included.
Guirguis A. The Pharmaceutical Journal. 2020;304.
Users of illicit substances are vulnerable to a variety of health concerns. This article discusses how the COVID-19 pandemic places illicit drug users at increased risk for COVID-19 due to their predisposition to infection and social contact; how disruptions to illicit drug supply chains increase risk for overdose due to drug substitution and; the impact of missing out on drug treatment services. The piece highlights the role of pharmacists in keeping this marginalized patient population safe.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Sarina Fazio, PhD, RN and Rachelle Firestone, PharmD, BCCCP |
A patient with multiple comorbidities and chronic pain was admitted for elective spinal decompression and fusion. The patient was placed on a postoperative patient-controlled analgesia (PCA) for pain control and was later found unresponsive. The case illustrates risks associated with opioid administration through PCA, particularly among patients at high risk for postoperative opioid-induced respiratory depression.
WebM&M Cases
Michelle Hamline, MD, PhD, MAS, Georgia McGlynn, RN, MSN-CNL, CPHQ, Andrew Lee, PharmD, and JoAnne Natale, MD, PhD |
After undergoing a complete atrioventricular canal defect repair, an infant with trisomy 21 was transferred to the pediatric intensive care unit (PICU) and total parenteral nutrition (TPN) was ordered due to low cardiac output. When the TPN order expired, it was not reordered in time for cross-checking by the dietician and pediatric pharmacist and the replacement TPN order was mistakenly entered to include sodium chloride 77 mEq/100 mL, a ten-fold higher concentration than intended. The commentary explores the safety issues with ordering TPN and custom intravenous fluids in a pediatric population, and the critical role of clinical decision support systems and the healthcare team (physicians, pharmacists, nurses and dieticians) in preventing medication-related errors.
WebM&M Cases
Catherine Chia, MD and Mithu Molla, MD, MBA |
A 55-year old man was admitted to the hospital for pneumonia requiring intravenous antibiotics. After three intravenous lines infiltrated, the attending physician on call gave a verbal order to have a percutaneous intravenous central venous catheter placed by interventional radiology the next morning. However, the nurse on duty incorrectly entered an order for a tunneled dialysis catheter, and the radiologist then inserted the wrong type of catheter. The commentary explores safety issues with verbal orders and interventional radiology procedures.
This Month’s Perspectives
Interview
Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at the Food and Drug Administration. We spoke with him about the role of the Food and Drug Administration in ensuring the safety of medical devices.
Interview
Joel Willis, DO, PA, MA, MPhiL is a Health Policy Fellow affiliated with the American Board of Family Medicine and the George Washington Medical Faculty Associates. Neal Sikka, MD is an Associate Professor and Attending Physician at George Washington Medical Faculty Associates and the Chief of the Innovative Practice and Telehealth Section of the Department of Emergency Medicine. We discussed with them how telehealth at GW is helping to protect patients and providers during the COVID-19 crisis.
Stay Updated!
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. Sign up today to get weekly and monthly updates via emails!
