August 17, 2005 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.
Ursprung R. Qual Saf Health Care. 2005;14(4):284-289.
This pilot study evaluated the feasibility of using a safety auditing checklist during daily work in an intensive care unit. Investigators developed a 36-item list focused on errors common to this clinical setting and implemented them into rounds on a regular basis for the 5-week study period. Results suggested the ability to detect a variety of errors while engaging staff in a blame-free fashion to stimulate immediate changes in performance. The authors advocate for greater application of safety and error prevention methods into routine clinical work as a mechanism for ongoing quality improvement.
Briant R, Morton J, Lay-Yee R, et al. N Z Med J. 2005;118(1219):U1591.
The authors analyzed surgical adverse events to assess the occurrence, cause, patient impact, and preventability of the incidents. They found that the surgical events increased average lengths of stay by 9.9 days and have a lower level of preventability than other types of adverse events.
Spigelman AD, Swan J. ANZ J Surg. 2005;75(8):657-61.
The authors surveyed users of the Australian Incident Monitoring System (AIMS) to determine its value for organizing and learning from data, promoting a safety culture, and increasing awareness of patient safety.
Kho ME. Quality and Safety in Health Care. 2005;14(4).
This study examined the utility of three safety climate instruments and compared their consistency in measuring desired outcomes. Investigators administered the different tools to staff in four intensive care units and report on the test characteristics of each. The authors advocate for more rigorous evaluation of safety climate tools if they are to effectively measure the success of safety interventions in different clinical settings.
Tomolo A, Caron A, Perz ML, et al. J Gen Intern Med. 2005;20(8).
The authors discuss the pilot of a tool that infuses systems thinking concepts into patient safety education. Their results suggest that the process increased student awareness of patient safety issues.
Naveh E, Katz-Navon T, Stern Z. Manage Sci. 2005;51(6):948-960.
The authors identify four safety climate dimensions pertaining to employee perceptions of safety efforts and discuss the implications for reducing medical errors.
Weingart SN, Pagovich O, Sands DZ, et al. J Gen Intern Med. 2005;20(9):830-6.
In this prospective study, investigators used post-discharge interviews and medical record review to capture the frequency and types of adverse events as reported by patients. The authors enrolled 228 patients hospitalized on an inpatient medical service and discovered that 8% reported suffering an adverse event. Discussion includes detailed analysis of the reported events and comparison to those noted in the medical record and from hospital incident reports. The authors conclude that engaging patients in the identification of medical errors may offer an additional and equally important approach to improving patient safety.
Commentary
Classic
Sachs BP. JAMA. 2005;294(7):833-840.
Part of a series in JAMA entitled Clinical Crossroads, this case study discusses the unfortunate events surrounding a 38-year-old woman’s presentation to a labor and delivery unit. The case details a seemingly routine full-term pregnancy that rapidly evolved into a course of complications, ultimately leading to a fetal death, a hysterectomy, and a prolonged hospital course. The discussion shares the experience through the eyes of the patient, her husband, and the primary obstetrician. Further exploration of the case identified several specific factors and broader systems issues that contributed to the events. The author shares how this particular institution responded with overarching changes, including a greater emphasis on teamwork, communication, and appropriate staffing of labor and delivery units to promote safety.
Pronovost PJ. Quality and Safety in Health Care. 2005;14(4).
This commentary provides an overview of the origin and use of safety climate surveys and suggests effective methods for using the tools.
Kalra J, Massey L, Mulla A. J R Soc Med. 2005;98(7):307-309.
The authors summarize open disclosure efforts in several countries, highlighting central issues within each system.
ED Manag. 2005;17(7):73-5.
This article provides practical advise for emergency department managers as they work to implement JCAHO's patient safety goals.
Commentary
Elwyn G, Corrigan JM. BMJ. 2005;331(7512):302-304.
The authors provide a brief history of the patient safety movement and insights into why the time is right to implement change in worldwide health care safety.
Bolsin S, Faunce T, Colson M. Aust Health Rev. 2005;29(3):297-305.
The authors outline a model for using personal digital assistants (PDAs) to increase rates of incident reporting and facilitate data analysis. The model has been successfully introduced in several Australian hospitals.
Friesen MA, Farquhar MB, Hughes RG. Center for American Nurses.
The authors introduce readers to how organizational culture affects safety and how nurses can help their organizations promote patient safety efforts. Continuing education contact hours are available for reading this material.
No results.
Elizabeth A. Flynn, PhD|
September 1, 2006
A woman admitted for heart and respiratory failure is mistakenly given penicillamine (a chelating agent) rather than penicillin (an antibiotic).
Bernard Lo, MD|
September 1, 2006
An elderly woman who had a DNR in place took a fall that required her to have surgery. Discussion with the patient's health care proxy led to the DNR order being suspended during surgery, with the understanding that it would be reinstated postoperatively. Several days later, a nurse noticed that patient remained 'full code' because the DNR had not been restored.
Book/Report
Youngberg B. ed. Sudbury, MA: Jones and Bartlett; 2013. ISBN 9780763774042
This revised edition of a comprehensive resource on patient safety includes new chapters discussing such topics as the complexity of defining error and the need for medical and nursing education to develop leadership skills to help drive improvement efforts.
Multi-use Website
National Health Service.
This Web site provide resources for improving patient safety in the National Health Service, including a place for practitioners to ask questions and share experiences with one another.
Newspaper/Magazine Article
Rogoski RR. Health management technology. 2005;26(8):12, 14, 16-7.
This article reports on two efforts to reduce medical errors through information technology implementation.
Arpana R. Vidyarthi, MD|
September 1, 2006
An elderly man was admitted to the hospital for pacemaker placement. Although the postoperative chest film was normal, the patient later developed shortness of breath. Over the course of several nursing and physician shift changes and signouts, results of a follow-up stat x-ray are not properly obtained, delaying discovery of the patient's pneumothorax.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute Care Edition. June 30, 2005;10.
This alert cautions against the use of automated medication-refill kiosks.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Richard H. White, MD |
An intern increases a patient's warfarin dosage nightly based on subtherapeutic INR levels drawn each morning; after several days, the patient develops potentially life-threatening bleeding.
WebM&M Cases
Jeffrey M. Pearl, MD; Nancy E. Donaldson RN, DNSc |
A nurse preparing a patient for transfer out of the ICU discovers the guidewire used for central line placement (1 week earlier) still in the patient's leg vein.
WebM&M Cases
D. John Doyle, MD, PhD |
Following surgery, a woman receives morphine via a patient-controlled analgesia (PCA) pump. A few hours after arriving on the floor, she is found barely breathing.
This Month’s Perspectives
Perspective
Linda H. Aiken, PhD, RN |
The goal set by the Institute of Medicine (IOM) in 1999 to reduce medical errors by half within 5 years has not been achieved. Opinion polls of consumers and health professionals show that concerns about patient safety remain high. Yet only 16% of hospital...
Interview
Barbara A. Blakeney, MS, RN, is President of the 150,000-member American Nurses Association (ANA). A nurse practitioner and expert in public health practice, policy, and primary care, Ms. Blakeney is on leave from the Boston Public Health Commission, where she has been director of health care services for the homeless. She is the recipient of numerous awards and has been named to Modern Healthcare Magazine's list of the 100 most influential people in health care for the past 3 years.
