August 17, 2011 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.
Steelman VM, Cullen JJ. AORN J. 2011;94(2):132-41.
A prospective failure mode and effect analysis identified 57 potential failures that each could lead to a retained surgical instrument. Most of these potential failures require technological rather than educational or policy-based solutions.
Robson J, de Wet C, McKay J, et al. Postgrad Med J. 2011;87(1033):750-6.
This survey found that while residents generally supported voluntary error reporting, a large proportion did not feel such reports were useful, nor did they believe that near misses should be reported.
Wetterneck TB, Walker JM, Blosky MA, et al. J Am Med Inform Assoc. 2011;18(6):774-782.
This study found that after implementation of computerized provider order entry (CPOE) with robust decision support in two adult intensive care units, the rate of duplicate medication orders increased dramatically. Analysis by a physician and a human factors engineer identified several contributing causes. These ranged from limitations of the system itself (orders for electrolyte repletion were often entered immediately before and immediately after physician shift change, as the CPOE system did not reliably display completed orders) to changes in team workflow (prior to CPOE, only one member of the team would write medication orders on rounds, whereas with CPOE multiple team members could enter orders more or less simultaneously). Similar issues have been documented in prior studies of the unintended consequences of CPOE.
Bagian JP, King BJ, Mills PD, et al. BMJ Qual Saf. 2011;20(11):974-82.
The Veterans Affairs system improved the timeliness and quality of root cause analysis by implementing a formal recognition program tied to specific quality improvement goals.
Chang CA, Strahan R, Jolley D. J Digit Imaging. 2011;24(4):724-8.
This study documented a low but consistent error rate in the transcription of dictated radiology reports; 2% to 5% of reports contained an error that may have affected patient management.
Stevenson JE, Nilsson G. J Adv Nurs. 2012;68(3):667-76.
This qualitative study among Swedish nurses found that many perceived their electronic medical record system was not designed in a user-centered fashion, as important clinical information was difficult to both enter and access in real time.
Booth CMA, Moore CE, Eddleston J, et al. Postgrad Med J. 2011;87(1032):694-9.
The obesity epidemic is considered an urgent public health issue in Europe and the United States. Although patients with obesity are prone to a variety of medical issues, no study to date has evaluated patient safety risks in this population. This retrospective analysis of errors voluntarily reported to the United Kingdom's National Patient Safety Agency documents more than 380 errors and near misses in which obesity was considered a contributing factor. The majority of errors were partly attributable to inadequate equipment for caring for such patients, particularly in the surgical and critical care environments. Based on these data, the authors advocate for multidisciplinary approaches to systematizing care for patients with obesity. The challenges of caring for patients with obesity are discussed in an AHRQ WebM&M commentary, which examined a case of an ultimately fatal delayed diagnosis in an woman with obesity.
Adelstein B-A, Piza MA, Nayyar V, et al. J Crit Care. 2011;26(6):635.e11-8.
Introduction of a rapid response system did not reduce the time between the onset of clinical deterioration and the institution of therapeutic measures.
Etchells E, Adhikari NKJ, Wu RC, et al. BMJ Qual Saf. 2011;20(11):924-30.
In this study, clinicians were notified in real time about critical lab test abnormalities and provided with immediate decision support. However, this intervention did not prevent adverse events attributable to the critical test results, nor did it seem to result in more timely management.
Kaplan T, Pilcher J. J Nurses Staff Dev. 2011;27(4):187-90.
This article describes an intensive care unit internship that utilized a Clinical Safety Investigation room, or Room of Horrors, to educate and engage nurses in practicing safety in everyday care.
Pashley HS. AORN J. 2011;94(2):194-8.
This commentary discusses a case in which a nurse served as a patient advocate for her mother and offers suggestions for nurses and physicians to improve patient safety.
Bell SK, Delbanco T, Anderson-Shaw L, et al. Chest. 2011;140(2):519-526.
The systems approach to analyzing medical errors holds that faulty systems, not irresponsible clinicians, are to blame for most preventable adverse events. That notwithstanding, individuals certainly bear some responsibility in most cases of errors, and a vigorous debate continues around the level of accountability required of clinicians and the consequences clinicians involved in errors should face. This review advances the concept of collective accountability—accountability at the level of the individual clinician, the health care team, and the institution—as a way to balance the distinction between systems issues and personal responsibility. Using an example case of a diagnostic error, the authors discuss how collective accountability would require clinicians and institutions to emphasize transparency in error disclosure and focus on optimizing team and system performance.
Ehrmeyer SS. Ann Saudi Med. 2011;31(4).
This review discusses the impact of point-of-care testing on patient safety and recommends areas for improvement.
Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; May 2011.
This report from the Lucian Leape Institute summarizes six concepts that require system-level attention and reveals potential concerns associated with health information technology.
Newspaper/Magazine Article
Urman RD, Shapiro FE. APSF Newsletter. 2011;3-4,9.
This piece discusses an ambulatory surgery safety improvement program and describes its background, goals, and checklist initiative.
Multi-use Website
MedStar Health.
This Web site hosts information on human factors engineering and describes how it can improve health care quality and safety.
Newspaper/Magazine Article
Sun LH.
This newspaper article reports on one hospital's implementation of an alert system designed to encourage frontline personnel to report close calls.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Margaret Fang, MD, MPH; Raman Khanna, MD, MAS |
Following hospitalization for community-acquired pneumonia, an elderly man with a history of dementia, falls, and atrial fibrillation is discharged on antibiotics but no changes to his anticoagulation medication. One week later, the patient’s INR was dangerously high.
WebM&M Cases
Harriette Gillian Christine Van Spall, MD; Robby Nieuwlaat, PhD; and R. Brian Haynes, MD, PhD |
A man with HIV disease and a recent diagnosis of CNS toxoplasmosis presented to the ED for the third time in two weeks with headaches, seizures, and right-sided weakness. Physicians pursued a workup for treatment-resistant toxoplasmosis or another brain disease, but discovered that the patient had run out of his toxoplasmosis medications.
WebM&M Cases
John Q. Young, MD, MPP |
A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer.
This Month’s Perspectives
Interview
In charge of implementing the PSO initiative for AHRQ, Dr. Munier is Director of the Center for Quality Improvement and Patient Safety.
Perspective
Rory Jaffe, MD, MBA |
This piece discusses the process by which one professional organization became a PSO.
