Classics and Emerging Classics

This systematic review evaluated the impact of providing patients with access to electronic health records (EHR) on measures of quality of care (i.e., patient-centeredness, effectiveness, efficiency, timeliness, equity, and safety). Meta-analysis found that sharing EHRs with patients is effective in reducing HbA1c levels; the included studies generally found positive effects on patient-centeredness, health outcomes, and adherence to preventative services. However, the authors concluded that more methodologically robust studies are necessary to quantitatively assess the impact of sharing EHRs with patients.  

This article describes the use of a new accident analysis technique (CAST, or Causal Analysis based on Systems Theory), an alternative approach to root cause analysis. The CAST approach is based on the principle that accidents are not only the result of individual system component failures or errors but more generally result due to inadequate enforcement of constraints on the behavior of the system components (i.e., safety constraints enforced by controls, such as checklists).  Many adverse events (AEs) appear to be related to the design of the system involved and not attributable to unsafe individual behavior. This technique can be useful in identifying causal factors to help health care systems learn from mistakes and design systems-level changes to prevent future AEs.

This study compared medication errors detected using incident reports, the Global Trigger Tool method, and direct observations of patient records. Incident reports and the Global Trigger Tool more commonly identified medication errors likely to cause harm. Omission errors were commonly identified by all three methods, but identification of other errors varied. For example, incident reports most commonly identified wrong dose and wrong time errors. The contributing factors also varied by method, but in general, communication issues and human factors were the most common contributors.

To address the negative psychological impacts faced by healthcare workers during the COVID-19 crisis, the authors of this commentary recommend three strategic principles for healthcare institutions responding to the pandemic: Encourage leadership to focus on resilience  Ensure that crisis communication provides both information and empowerment Create a continuum of staff support within the organization to address a surge in mental health concerns among healthcare workers.

This article reviewed 74 academic and 10 policy resources, as well as interviewed 13 experts, to understand how to effectively integrate patient-centric complaint handling with quality monitoring and improvement. Findings highlight the need for standardized methods to use and report complaints data, novel policy strategies, and analysis strategies to generate actionable learning insights and translation into quality improvement by affecting leadership and safety culture are discussed.

This paper describes the implementation of a "second victim" peer-support program in the surgery department at a tertiary care center. The program trained surgical attendings and trainees to provide peer-support for other surgeons involved in major adverse events. After one-year follow-up, 81% of affected surgeons elected to receive peer support. The majority (81%) felt the program had a positive impact on safety culture by providing a confidential, safe, and timely intervention for so-called "second victims". A 2011 Perspective on Safety with Dr. Albert Wu discussed ways that organizations can support "second victims."

Medical errors occur frequently but there is great variability in whether they are reported. Focus groups and one-on-one interviews were used in this study to determine the effect of hospital culture and climate on employee decisions to speak up–or not–about medical errors. The authors conclude that their results, gathered from a large hospital in a mid-sized city in the midwestern U.S., indicate this hospital’s culture does not facilitate reporting of medical errors and suggest that creating a positive organizational culture can both promote speaking up about medical errors and increase patient safety.

Surgeon technical skill, real-time problem solving, and communication quality are essential for avoiding harm during surgery. This study found that those types of human errors were responsible for 51.6% of 188 surgical adverse events at 3 hospitals. A past PSNet perspective delineates the evolution of surgical patient safety.

High-risk opioid prescribing by providers contributes to opioid misuse. This systematic review sought to identify factors that confer risk for opioid addiction and thereby suggest which patients can safely take opioids. Researchers found that a prior history of substance use disorder, prescription of psychiatric medications, certain mental health diagnoses, higher daily opioid doses, and prescription of opioids for 30 days or more may confer risk for opioid addiction. The only factor associated with a lower risk of opioid use disorder was absence of a mood disorder. They could not identify any screening instruments or tools that accurately risk-stratified individuals' likelihood of opioid addiction. An Annual Perspective discussed problematic prescribing practices that likely contribute to adverse events and described promising practices to foster safer opioid use.

Drug shortages are a complex worldwide challenge to safe patient care. This review found economic, clinical, and psychosocial consequences associated with medication shortages for both patients and organizations. Highlighting weaknesses in the evidence base that stem from lack of data consistency, the authors describe the need for structured data on the medication shortage phenomenon to clarify their impact on patients across developed and developing countries. A WebM&M commentary explored medication safety in the context of drug shortages.

Having multiple patient records open in the electronic health record increases the potential risk of wrong-patient actions. This randomized trial tested two different electronic health record configurations: one allowed up to four patient records to be open at a time, and the other allowed only one to be open. Among the 3356 clinicians with nearly 4.5 million order sessions, there were no significant differences in wrong-patient orders. However, the investigators noted that clinicians in the multiple records group placed most orders with just one record open. A post hoc analysis determined that the rate of errors increased when orders were placed with multiple records open. A related editorial highlights the tradeoffs between safety and efficiency and argues for examining the context of the two configurations, including throughput and clinician satisfaction. A previous PSNet perspective discussed assessing and improving the safety of electronic health records.

Maternal safety is a critical concern in health care, and prior studies have discussed racial and ethnic disparities in patient safety. The Centers for Disease Control and Prevention examined trends in pregnancy-related deaths between 2011 and 2015. This analysis found that black women had rates of maternal mortality 3.5 times that of white women; Native American/Alaska Native women had rates 2.5 times higher than white women. About 60% of deaths were deemed preventable, and leading causes included cardiovascular events such as venous thromboembolism, infection, and hemorrhage. The study team recommends implementing interventions at health system, provider, community, and patient levels to prevent maternal mortality. A recent Annual Perspective on maternal safety touched on the persistently higher death rates among black women and discussed national initiatives to improve outcomes in maternity care.

Debriefing after a critical event is a strategy drawn from high reliability industries to learn from failures and improve performance. This retrospective study of critical events in inpatient anesthesiology practice found that debriefing occurred in 49% of the incidents. Debriefs were less likely to occur when critical communication breakdowns were involved, and more than half of crisis events included at least one such breakdown. Interviews with care teams revealed that communication breakdowns present in some incidents impeded the subsequent debriefing process. The authors call for more consistent implementation of debriefing as a recommended patient safety process. A previous WebM&M commentary discussed an incident involving miscommunication between a surgeon and an anesthesiologist.

Hospital-acquired pressure ulcers are considered never events and represent a significant source of patient harm. This systematic review and meta-analysis found a pooled incidence of 12% for pressure injuries related to the use of medical devices.

Overuse of unnecessary tests and procedures contributes to patient harm. In this cohort study, researchers found that patients who developed a hospital-acquired condition after undergoing a procedure that most likely should not have been performed had longer lengths of stay than patients who did not develop a hospital-acquired condition.

The degree to which sepsis contributes to inpatient mortality and the extent to which sepsis-associated inpatient mortality is preventable remains unknown. In this retrospective cohort study, researchers analyzed the medical records of 568 adult patients hospitalized at 6 United States hospitals who either died during the hospitalization or were discharged to hospice. They found a diagnosis of sepsis was present in 300 cases and that it was the main cause of death in 198 cases. Reviewers rated 11 of the 300 sepsis-associated deaths as definitely or moderately likely preventable. The authors conclude that it may be challenging to further reduce sepsis-associated inpatient mortality.

This survey of medical inpatients at five academic medical centers in Finland aimed to elicit patients' perceptions of safety and experience of errors. Investigators found that encouragement from staff, education about patient safety, and comprehensible information all led to higher participation rates. The authors conclude that patients will be more engaged in their safety if frontline staff value patient involvement.

Patient engagement in safety takes many forms: patients may report unique safety incidents, encourage adherence to best medical practice, and coproduce improvement initiatives. Family-centered rounding in pediatrics invites families to express concerns, clarify information, and provide real-time input to the health care team. This pre–post study explored the safety impact of Patient and Family Centered (PFC) I-PASS rounds on 3106 admissions in pediatric units at 7 hospitals. Family-centered rounds reduced both preventable and nonpreventable adverse events. They also improved family experience without substantially lengthening rounding time. A past PSNet interview discussed the safety benefits of structured communication between health care providers and family members.

An unintentionally retained foreign object during a surgery or a procedure is considered a never event and can result in significant patient harm. Researchers retrospectively reviewed 308 events involving unintentionally retained foreign objects that were reported to The Joint Commission to better characterize these events, determine the impact on the patient, identify contributing factors, and make recommendations for improving safety.

Factors in the hospital work environment can affect nurses' ability to provide safe care. In this survey study, investigators examined trends in nurse ratings of their work environment and patient ratings of care quality at 535 hospitals between 2005 and 2016. Over this time frame, about 20% of hospitals showed significant improvements in work environment scores, while 7% of hospitals demonstrated declining scores. There was an association between an improving work environment and better patient satisfaction. The authors conclude that lack of improvement in work environments may worsen safety culture and impede efforts to enhance patient safety. A PSNet interview with Linda Aiken discussed how nurse staffing and the work environment can affect patient safety and outcomes.