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October 23, 2024 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.
This Week’s Featured Articles
Gleason KT, Dukhanin V, Peterson SK, et al. J Patient Saf. 2024;20(7):498-504.
Given the nature of emergency department and urgent care, patients do not typically return to the same clinician for follow-up care, limiting opportunities for direct feedback on diagnostic performance. Many health systems do, however, send follow up surveys after discharge, which presents an opportunity to solicit patient information on diagnostic performance. This article describes the development and psychometric testing of a post-discharge survey, Patient-Report to IMprove Diagnostic Excellence in Emergency Department settings (PRIME-ED). Responses showed high internal consistency in the three domains groups: diagnostic process, accuracy of diagnosis, and communication of diagnosis.
Grogan L, Peterson E, Flatley M, et al. Am J Perinatol. 2024;Epub Aug 29.
A patient safety bundle is a set of evidence-based interventions that has been shown to improve outcomes and safety in health care when performed consistently and reliably. This article describes a quality improvement project to implement the Alliance for Innovation on Maternal Health's Severe Hypertension in Pregnancy patient safety bundle to increase the percentage of patients who receive evidence-based treatment during hypertensive emergencies. After several cycles of plan-do-study-act, the percentage of patients receiving appropriate treatment increased from 64% to more than 80% and was sustained for 6 months.
Vaismoradi M, Rae J, Turunen H, et al. Digit Health. 2024;10:20552076241287272.
As management of many acute and chronic conditions shifts to outpatient and community settings, telehealth is increasing in use. In this scoping review, the authors explore how specialized nurses (e.g., advanced practice nurses, nurse practitioners) advance patient safety through telehealth in home care. Based on 23 included studies, the authors identified several ways in which specialized nurses leverage telehealth to enhance patient safety in home care, such as increasing patient and caregiver confidence and satisfaction, monitoring and timely intervention, supporting patient engagement and adherence, and promoting medication safety.
Pashtan IM, Kosak T, Shin K-Y, et al. Pract Radiat Oncol. 2024;14(4):343-352.
Trigger tools, alerts, and other criteria are used to identify potentially inappropriate prescribing and reduce adverse medication events. In this study, researchers reviewed over 24,000 radiation oncology prescriptions and applied criteria to identify clinically inappropriate prescriptions. The trigger tool generated 241 alerts, 31% of which led to prescription changes.
Snyder ME, Nguyen KA, Patel H, et al. BMC Health Serv Res. 2024;24(1):1194.
Health information exchange (HIE) tools allow healthcare systems to electronically share patient information across different settings and can improve care coordination and communication. This study explored the facilitators and barriers to effective use of HIE tools for medication reconciliation among VA clinicians. The 63 participating clinicians shared facilitators encouraging HIE use, including familiarity with the software and confidence accessing necessary information. They also identified several barriers to HIE use, including information overload and lack of integration with other EHR interfaces.
Gleason KT, Dukhanin V, Peterson SK, et al. J Patient Saf. 2024;20(7):498-504.
Given the nature of emergency department and urgent care, patients do not typically return to the same clinician for follow-up care, limiting opportunities for direct feedback on diagnostic performance. Many health systems do, however, send follow up surveys after discharge, which presents an opportunity to solicit patient information on diagnostic performance. This article describes the development and psychometric testing of a post-discharge survey, Patient-Report to IMprove Diagnostic Excellence in Emergency Department settings (PRIME-ED). Responses showed high internal consistency in the three domains groups: diagnostic process, accuracy of diagnosis, and communication of diagnosis.
Grogan L, Peterson E, Flatley M, et al. Am J Perinatol. 2024;Epub Aug 29.
A patient safety bundle is a set of evidence-based interventions that has been shown to improve outcomes and safety in health care when performed consistently and reliably. This article describes a quality improvement project to implement the Alliance for Innovation on Maternal Health's Severe Hypertension in Pregnancy patient safety bundle to increase the percentage of patients who receive evidence-based treatment during hypertensive emergencies. After several cycles of plan-do-study-act, the percentage of patients receiving appropriate treatment increased from 64% to more than 80% and was sustained for 6 months.
Burney RE, Mckeown ES, Zhang Y, et al. J Patient Saf Risk Manag. 2024;Epub Sep 24.
Communication and resolution programs (CRP) are intended to promote open communication among patients, providers, and organizations; improve transparency and accountability; and reduce the need for lawsuits. This article follows up a 2010 study on the impact of Michigan Medicine's CRP. During the most recent 10-year period, the rate of claims decreased, with 92% being closed or settled internally. Other measured outcomes, such as time to resolve claims, remained stable or decreased.
Franciscovich CD, Bieniek A, Dunn K, et al. Jt Comm J Qual Patient Saf. 2024;Epub Sep 24.
Automated dispensing cabinets (ADC) can improve efficiency in drug administration but pose risks when pharmacist approval is improperly or frequently overridden. This article describes a children's hospital's intervention to decrease ADC overrides in the peri-anesthesia care unit, with a secondary focus on midazolam overrides. The overall override rate decreased from 17% to 4% by the end of the 18-month project period, with a decrease from 22% to 3% for midazolam. While not an aim of the project, time to pharmacist verification also decreased, thus potentially lessening the need for overrides.
Huber A, Moyano B, Blondon K. BMC Med Educ. 2024;24(1):1046.
The mnemonic I-PASS (Illness severity, Patient summary, Actions list, Situation awareness, Synthesis) has been shown to improve communication between providers during handoffs. This simulation study compared usual resident handoffs to "gold standard" I-PASS handoffs, focusing on relevance of information, completeness, and distribution of the first four I-PASS categories (synthesis was not measured as part of this study). Relevance and completeness rates were 37% and 52%, respectively. More than half of the handoffs did not include Situation Awareness, and the most common order of categories was Patient, Illness severity, Actions list.
Kirkman A, Tripp H, Ward L, et al. AORN J. 2024;120(4):226-237.
As seen during recent global and regional crises, disasters challenge the delivery of safe care. This article describes key elements for providing education across the disaster continuum: preimpact, impact, postimpact. Under the direction of a command center team, key elements include a structured team, centralized communication, and postimpact evaluation.
Jeraj S. BMJ. 2024;386:q1943.
Analysis of system failure is only the beginning of the improvement cycle. This article discusses an effort in the United Kingdom to learn from preventable deaths reported to coroners that occurred in variety of environments, including health care. The author suggests that the process has not realized its potential to reduce system weaknesses noted by state examiners due to a perceived lack of oversight and follow-through on recommendations.
Clark D, Lawton R, Baxter R, et al. BMJ Qual Saf. 2024;Epub Sep 27.
Workarounds have the potential to degrade patient safety. This systematic review sought to identify circumstances in which workarounds are applied. More than half of the identified studies focused on medication safety, such as workarounds related to barcode scanning. Organizational factors, including workload and time pressure, were identified in 93% of studies. Several studies reported that workarounds did not result in error or harm or could simultaneously have positive and negative implications.
Witkowska MI, Janhunen K, Sak‐Dankosky N, et al. J Adv Nurs. 2024;Epub Aug 9.
Parents and caregivers often have unique perspectives about healthcare safety and quality. This systematic review of 12 studies identified several factors influencing parents’ perspectives on pediatric patient safety in hospital settings, such as parental engagement and communication abilities and difficulties. The authors conclude that parents need to be treated as valuable partners but require support and improved communication from healthcare professionals to ensure the safety of their children.
Alabdullah H, Karwowski W. Appl Sci. 2024;14(18):8496.
Establishing a strong patient safety culture is a global public health goal. This systematic review identified 75 research studies from around the world that used the Hospital Survey on Patient Safety Culture to measure patient safety culture in hospitals. Teamwork and organizational learning emerged as strengths, and non-punitive responses to error and staffing surfaced as weaknesses across continents. Nurses comprised the largest response group and rated patient safety culture lower than other staff groups did.
Vaismoradi M, Rae J, Turunen H, et al. Digit Health. 2024;10:20552076241287272.
As management of many acute and chronic conditions shifts to outpatient and community settings, telehealth is increasing in use. In this scoping review, the authors explore how specialized nurses (e.g., advanced practice nurses, nurse practitioners) advance patient safety through telehealth in home care. Based on 23 included studies, the authors identified several ways in which specialized nurses leverage telehealth to enhance patient safety in home care, such as increasing patient and caregiver confidence and satisfaction, monitoring and timely intervention, supporting patient engagement and adherence, and promoting medication safety.
No results.
Makary M. New York, NY: Bloomsbury Publishing; 2024. ISBN 9781639735310.
Respectful skepticism is a noted element of innovation and professional dialogue, as challenges to embedded methods can reveal the need for change. This book discusses systemic failures caused by an overreliance on erroneous or out-of-date approaches to care that were broadly accepted and harmed patients across the health care system.
Book/Report
Washington DC: The Leapfrog Group; September 2024.
Data collection and transparency are known to motivate change and drive improvement efforts. This series of reports draws from Leapfrog survey participants that volunteer data to inform action resulting in better patient outcomes. The latest report examines hand-hygiene efforts since 2020 and tracks advancements realized using tactics such as electronic monitoring and leadership accountability.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Garth Utter, MD |
A 38-year-old man sustained multiple injuries in a motorcycle crash, including head trauma, chest injuries, and spinal fractures. Attempts to intubate him to manage his respiratory distress were unsuccessful and he underwent emergency cricothyroidotomy. Despite initial neurological evaluations indicating normal extremity movements, he developed progressive paralysis of his lower extremities over the hospital course. A delayed MRI revealed a significant epidural hematoma compressing his spinal cord from C3 to C7, prompting emergency surgery. Despite decompression, he suffered permanent paralysis. The commentary highlights the cognitive pitfalls associated with managing and processing large volumes of clinical information and the importance of effective communication and active engagement among all clinical team members.
WebM&M Cases
Spotlight Case
Ryan Martin, MD, FCNS and Kiarash Shahlaie, MD, PhD, FAANS, FCNS |
A man in his mid-50s presented to the hospital with a persistent headache after a sledding injury. A head CT scan was read as normal and he was diagnosed with a minor head injury and discharged without any specific treatment. Three weeks later, he presented with ongoing symptoms including worsening cognition and increased headache and was diagnosed with post-concussive syndrome and discharged without specific treatment. He was later diagnosed with a large frontal subdural hematoma requiring urgent surgery. The commentary discusses risk factors for delayed acute subdural hematoma and the importance of repeat brain imaging in patients with risk factors and persistent symptoms.
WebM&M Cases
Victoria Jackson, DNP, RN, PHN, FNP-C, PA-C and Anna Satake, PhD, MSN, GCNS, RN |
These cases involve two elderly patients presenting to the emergency department (ED) who suffered falls during their care, despite recognition of risk factors including previous ground-level falls. The commentary summarizes risk factors for fall injuries among high-risk populations (such as older adults), appropriate use of fall assessment and prevention strategies, and strategies to improve communication between healthcare team members to reduce the risk of patient falls.
This Month’s Perspectives
Interview
Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd |
Elizabeth Salisbury-Afshar, MD, MPH, is an Associate Professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health and Medical Director of the Compass Program, a low-barrier walk-in clinic for substance-related health concerns.
Perspective
Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd |
This piece provides an overview of the philosophy of harm reduction, as well as specific strategies for how it can improve safety for people who use substances.
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