Email Updates
September 16, 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.
Fleischman W, Ciliberto B, Rozanski N, et al. Am J Emerg Med. 2020;38:1072-1076.
In this prospective study, researchers conducted direct observations in one urban, academic Emergency Department (ED) to determine whether and which ED monitor alarms led to observable changes in patients’ care. During 53 hours of observation, there were 1,049 alarms associated with 146 patients, resulting in clinical management changes in 5 patients. Researchers observed that staff did not observably respond to nearly two-thirds of alarms, which may be a sign of alarm fatigue.
Dharamsi A, Hayman K, Yi S, et al. J Hosp Infect. 2020;105:604-607.
This article describes the use of a rapid-cycle in-situ simulation (ISS) program to facilitate identification and resolution of organizational and systems-level safety threats (i.e., latent safety threats) involving a possible COVID-19 case. Identified threats fell in four domains: personnel, personal protective equipment, supply/environment, and communication. Most participants felt better prepared to provide care after the ISS training.
Gupta A, Quinn M, Saint S, et al. Diagnosis (Berl). 2021;8:167-175.
This article describes the use of a case-based simulation to explore how physicians reason, create differential diagnoses, and ultimately achieve a correct diagnosis. Participating physicians who achieved the correct diagnosis (herpes zoster) utilized systems-based or anatomic approaches, rather than focuses on life-threatening diagnoses alone, and employed debiasing strategies.
Decesare JZ, Bush SY, Morton AN. J Patient Saf. 2020;16:e179-e181.
This article reports on the impact of an OB hospitalist program on serious safety events in one hospital over a two-year period. After program implementation, there was a significant reduction in serious safety events.
Blazin LJ, Sitthi-Amorn J, Hoffman JM, et al. Pediatr Qual Saf. 2020;5:e323.
This article describes one pediatric hospital’s experience adapting and implementing the I-PASS handoff program for inpatient nursing bedside report, physician handoff, and imaging/procedures handoff. The project demonstrates that I-PASS can be successfully used across a hospital system in various settings to reduce handoff-related errors.
Barreveld AM, McCarthy RJ, Elkassabany N, et al. Anesthesiology. 2020;132:1558-1568.
This article discusses the impact of a 6-month opioid use educational program for anesthesiologists on opioid-related harm among hospitalized adults. The program was implemented at 31 hospitals and outcomes were compared to 33 control hospitals. The researchers did not identify any significant reduction in opioid adverse events or altered opioid use in hospitalized patients in the intervention hospitals, as compared to the control hospitals.
Raffel KE, Kantor MA, Barish P, et al. BMJ Qual Saf. 2020;29:971-979.
This retrospective cohort study characterized diagnostic errors among adult patients readmitted to the hospital within 7 days of hospital discharge. Over a 12-month period, 5.6% of readmissions were found to contain at least one diagnostic error during the index admissions. These diagnostic errors were primarily related to clinician diagnostic reasoning, including failure to order needed tests, erroneous interpretation of tests, and failure to consider the correct diagnosis. The majority of the diagnostic errors resulted in some form of clinical impact, including short-term morbidity and readmissions.
Di Simone E, Fabbian F, Giannetta N, et al. Eur Rev Med Pharmacol Sci. 2020;24:7058-7062.
Based on survey data of a sample of nurses, the authors identified a significant association between perceived risk of near miss medication errors and both poor sleep quality and short resting time after a night shift.
McGarry BE, Grabowski DC, Barnett ML. Health Aff (Milwood). 2020;39:1812-1821.
Based on data from the CMS COVID-19 Nursing Home Database, this study found that more than 20% of nursing homes report a severe shortage of personal protective equipment (PPE) and shortage of staff; rates for staffing and PPE did not improve from May to July of 2020. Nursing homes with COVID-19 cases among residents and staff, and those with lower quality scores, were more likely to report shortages.
Bae S-H, Dang D, Karlowicz KA, et al. J Patient Saf. 2020;16:e148-e155.
Based on survey data, this study explored intrapersonal, interpersonal and organizational triggers resulting in disruptive and unprofessional behavior. All three types of triggers were significantly related to disruptive behavior among nurses; intrapersonal and interpersonal triggers were significantly related to disruptive behavior among clinicians. The most frequent triggers included pressures from high census; environmental overload; chronic, unresolved system issues; and personal characteristics or issues impeding job performance.
Ross P, Spates K. Jt Comm J Qual Patient Saf. 2020;46:596-599.
This article discusses healthcare safety and quality issues in artificial intelligence (AI) development and use (such as biases in AI tools) and approaches to increase transparency and understanding of AI tools among health care providers.
Angeli F, Montefusco A. World Dev. 2020;136:105106.
This analysis addresses the challenges of policymaking in complex crises, such as the COVID-19 pandemic, and presents a roadmap for learning based on a flexible and adaptive approach, local solutions, international cooperation, and transparent dissemination of data.
Bloomfield HE, Greer N, Linsky AM, et al. J Gen Intern Med. 2020;35:3323-3332.
Deprescribing is one strategy to reduce polypharmacy among older adults. This systematic review found that medication deprescribing interventions (particularly those involving comprehensive medication review) may provide small reductions in mortality and use of potentially inappropriate medications among community-dwelling older adults.
Maurer NR, Hogan TH, Walker DM. Med Care Res Rev. 2021;78:643-659.
This systematic review examined effectiveness of hospital- or system-wide interventions in reducing healthcare-associated infections (HAIs). The review identified several strategies for reducing HAIs, including enhanced environmental cleaning using disinfection technologies; EHR implementation; multimodal infection control programs; multichannel hand hygiene promotion; and hospital-wide cultural transformations. The review identifies approaches meriting additional research and exploration.
Boylen S, Cherian S, Gill FJ, et al. JBI Evid Synth. 2020;18:1360-1388.
In this systematic review, the authors synthesized evidence on the impact of professional interpreters on outcomes for hospitalized children from migrant and refugee families with limited English proficiency. The authors conclude that while video and in-person interpreters are more favorable for some outcomes, use of a professional interpreter of any mode was superior to the use of an ad hoc interpreter, or to no interpreter at all.
No results.
Newspaper/Magazine Article
O'Donnell J. USA Today. September 8, 2020
Management and clinical functions to ensure patient safety have been disrupted during the COVID-19 pandemic. This article discusses how tracking and submitting of reports of questionable medical care have been reduced due to redirection of efforts of all to managing pandemic related activities.
Newspaper/Magazine Article
Cheney C. HealthLeaders. September 4, 2020.
A blameless approach to error and near miss reporting is foundational to the success of the effort. This article discusses one organization’s persistent challenge with shifting reporting to align with a safety culture. The author describes the importance of staff education and leadership to support the focus of reporting initiatives on the system rather than individuals when failures occur.
Boston, MA: Institute for Healthcare Improvement: September 2020.
This National Action Plan developed by the National Steering Committee for Patient Safety – a group of 27 national organizations convened by the Institute for Healthcare Improvement – provides direction for health care leaders and organizations to implement and adapt effective tactics and supportive actions to establish the recommendations laid out in the plan. Its areas of focus include culture, leadership, and governance, patient and family engagement, workforce safety and learning systems.
Newspaper/Magazine Article
Waldman A, Kaplan J. ProPublica. 2020.
Hospitals have been deeply challenged to provide effective care during the COVID crisis. This article discusses how rationing and ineffective protection for families and patients may have contributed to preventable death and the spread of the virus in families due to unnecessary referrals of patients to home care and hospice.
Chicago, IL; Society to Improve Diagnosis in Medicine: August 2020.
Patients and families provide unique insights for leaders working to improve diagnosis. This report highlights how organizations can best implement patient advisory council programs to spark learning, enhance feedback, and support a safety culture that enhances the impact of those efforts.
Newspaper/Magazine Article
Brody JE. New York Times. 2020.
Inappropriate care activities can cascade to significantly impact patient safety. This article shares how medication side effects can be misdiagnosed to perpetuate harm in older patients rather than getting to the root of the care concerns.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Benjamin Stripe, MD, FACC, FSCAI and Dahlia Zuidema, Pharm.D, BC-ADM, CDCES |
A 44-year old man with hypertension and diabetes was admitted with an open wound on the ball of his right foot that could be probed to the bone and evidence of diabetic ketoacidosis. Over the course of the hospitalization, he had ongoing hypokalemia, low magnesium levels, an electrocardiogram showing a prolonged QT interval, ultimately leading to cardiac arrest due to torsades de pointes (an unusual form of ventricular tachycardia that can be fatal if left untreated). The commentary discusses the use of protocol-based management of chronic medical conditions, the inclusion of interprofessional care teams to coordinate management, and the importance of inter-team communication to identify issues and prevent poor outcomes.
WebM&M Cases
Kristine Chin, PharmD, Van Chau, PharmD, Hannah Spero, MSN, APRN, and Jessamyn Phillips, DNP |
This case involves a 65-year-old woman with ongoing nausea and vomiting after an uncomplicated hernia repair who was mistakenly prescribed topiramate (brand name Topamax, an anticonvulsant and nerve pain medication) instead of trimethobenzamide (brand name Tigan, an antiemetic) by the outpatient pharmacy. The commentary uses the Swiss Cheese Model to discuss the safety challenges of “look-alike, sound-alike” (LASA) medications, the importance of phyiscians employing “soft” skills during medication dispensing, and how medication administration errors can occur in outpatient pharmacy settings, despite multiple opportunities for cross-verification.
WebM&M Cases
Spotlight Case
Richard P. Dutton, MD MBA |
A 40-year-old man with multiple comorbidities, including severe aortic stenosis, was admitted for a pathologic pelvic fracture (secondary to osteoporosis) after a fall. During the hospitalization, efforts at mobilization led to a second fracture of the left femoral neck The case describes deviations in the plan for management of anesthesia and postoperative care which ultimately contributed to the patient’s death. The commentary discusses the importance of multidisciplinary planning for frail patients, the contributors to, and consequences of, deviating from these plans, and the use of triggers, early warning systems, and rapid response teams to identify and respond to early signs of decompensation.
This Month’s Perspectives
Interview
Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is the Senior Vice President of Integrated and Acute Care Services and the Chief Nursing Officer (CNO) at Parrish Medical Center in Titusville, Florida. We spoke with him about his experiences with the concept of safety across the board at his medical center.
Perspective
This piece discusses the concept of Safety Across the Board and reviews the three key components necessary for successful implementation in a healthcare organization: culture, strong safety processes, and engagement.
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