Email Updates
December 13, 2006 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.
Hofmann DA, Mark BA. Pers Psychol. 2006;59(4).
The authors looked at the association between safety climate and certain outcomes such as medication errors and nurse back injuries, as well as patient and nurse satisfaction.
Ogden PE, Sibbitt S, Howell M, et al. Acad Med. 2006;81(12):1026-31.
The authors describe their experiences in implementing changes at their institution to address the 2003 ACGME duty hour restrictions.
Blank FSJ, Henneman PL, Maynard AM, et al. Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Association. 2006;32(6):491-6.
The authors describe the implementation of a reporting program in an urban tertiary care facility, data elements collected from the reports, and improvements that were implemented in response to findings.
Barger LK, Ayas N, Cade BE, et al. PLoS Med. 2006;3(12):e487.
The institution of work hour regulations for housestaff in 2003 was intended to benefit physicians and patients, as prior research suggested a relationship between physician fatigue and medical errors. In this study, 2700 interns completed monthly surveys asking them to report their work hours and whether patients under their care experienced significant preventable medical errors. Previous articles analyzing the same survey data demonstrated that extended work shifts (working more than 24 consecutive hours) remain common for interns, and working extended shifts is associated with an increased risk of percutaneous injuries (eg, needle sticks). This study found that interns who worked extended shifts were much more likely to report both significant preventable errors and attentional failures (eg, falling asleep at work). An accompanying editorial notes that the laudable impetus to reduce housestaff work hours may result in a "dangerous tradeoff" between reducing work shifts and increasing discontinuity.
Vincent CA, Davy C, Esmail A, et al. J Eval Clin Pract. 2006;12(6):665-74.
The authors from the United Kingdom's Clinical Safety Research Unit discuss the use of malpractice claims review to learn about medical errors and adverse events. They propose that it is most useful for understanding particular cases.
Study
Classic
Davis TC, Wolf MS, Bass PF, et al. Ann Intern Med. 2006;145(12):887-94.
Poor health literacy has been identified as an important threat to patient safety, particularly through potentially contributing to adverse drug events. In this study, researchers surveyed patients in three urban primary care clinics serving predominantly indigent populations, and found that low health literacy was independently associated with misunderstanding of prescription drug label instructions. Although the study did not directly evaluate if misunderstanding led to medication errors, the study adds to a growing body of research documenting that patients with low and marginal health literacy have difficulty comprehending prescribing information. In the accompanying editorial, Dr. Dean Schillinger calls for development of standardized systems for transmitting medication instructions to patients in a clear and understandable fashion.
Lesar TS. Hosp Pharm. 2010;41(11):1053-1066.
Error in medication prescribing is a well-described problem in the hospital setting. This study sought to further characterize prescribing errors by determining the incidence of one specific type of error—errors in the route of administration. These errors were common, most frequently involving prescribing for the wrong route (eg, orally instead of intravenously), and cardiovascular drugs were most often implicated. The author provides suggestions for means of preventing these errors. A prior study by Lesar was one of the first to characterize the incidence of medication error in a teaching hospital setting, and he discusses the implications of error in the route of administration in a WebM&M commentary.
Ashcroft DM, Cooke J. Pharmacy World & Science. 2006;28(6).
The investigators examined the effectiveness of a Web-based reporting system to monitor types of medication errors and near misses, determine when they happen, and identify who reports them.
Commentary
Roberto MA, Bohmer RMJ, Edmondson A. Harv Bus Rev. 2006;84(11):106-13, 157.
This study describes how organizations respond to signs that may or may not portend future catastrophes. The authors examine the space shuttle Columbia disaster in depth, with particular attention to the group dynamics and organizational cultural barriers that combined to produce an ineffective response to the "ambiguous threat" posed by the foam damage to the shuttle's wing. Examples from health care, such as the deployment of rapid response teams, are used to illustrate how recognizing early signals, practicing teamwork, and encouraging experimentation can prevent ambiguous threats from developing into substantive threats. Bohmer and Edmondson have previously described the collective learning process that health care organizations should strive to achieve.
Asdigha MN. Hosp Pharm. 2010;41(11):1067-1075.
The author describes changes made within the neonatal intensive care unit to improve medication use safety, including eliminating the "rule of 6" for medication preparation and installing smart pump technology.
Babaie K. Case Manager. 2006;17(6):54-9.
The author describes a patient safety educational initiative to reduce readmissions after discharge and increase awareness about case management.
Hearns S, Shirley PJ. Emerg Med J. 2006;23(12):943-7.
The authors describe the retrieval and transfer of critically ill patients from one environment to another and provide recommendations for making this process as safe and reliable as possible.
Ziv A, Erez D, Munz Y, et al. Acad Med. 2006;81(12):1091-7.
The authors describe a simulation-based medical education center and how it changed the educational and patient safety cultures in the Israeli medical community.
No results.
No results.
Press Release/Announcement
Institute for Healthcare Improvement; IHI
The Institute for Healthcare Improvement's 100,000 Lives Campaign successfully engaged more than 3,000 US hospitals in a coordinated effort to reduce preventable inpatient deaths by delivering evidence-based care and preventing adverse events. Building on this effort, the 5 Million Lives Campaign aims to prevent 5 million incidents of medical harm (defined as "unintended injury due to medical care") in the next 2 years through the adoption of 12 patient safety interventions. Although the accomplishments of the 100,000 Lives Campaign are somewhat controversial, the current campaign includes the 6 interventions from 100,000 Lives and 6 additional interventions targeting major patient safety issues such as adverse drug events, health care-associated infections, and the culture of safety.
Multi-use Website
This research program was established to explore the nature of medical harm, study its causes, and understand how to improve the safety of health care.
Jonathan R. Genzen, MD, PhD, and Heather N. Signorelli, DO|
March 1, 2015
After presenting to the emergency department, a woman with chest pain was given nitroglycerine and a so-called GI cocktail. Her electrocardiogram was unremarkable, and she was scheduled for a stress test the next morning. A few minutes into the stress test, the patient collapsed and went into cardiac arrest.
Amanda Wollitz, PharmD, and Michael O'Connor, PharmD, MS|
March 1, 2015
Admitted to the hospital with chest pain, headache, and accelerated hypertension, an older man with a history of chronic kidney disease and essential hypertension who had missed several days of his regular medications was to be started back on them gradually. One of his antihypertensive medications (minoxidil) was ordered via the EHR, but a vasopressor/antihypotensive medication with a similar name (midodrine) was dispensed. Fortunately, a nurse noticed the discrepancy before administration.
Special or Theme Issue
Matlow A, Laxer RM, eds. Pediatr Clin North Am. 2006;53(6):1053-1276.
This special issue examines patient safety through the perspectives of parents, hospital leadership, human factors experts, and clinicians.
Newspaper/Magazine Article
Landro L. The Wall Street Journal. November 29, 2006.
This article describes a decision support program used by Kaiser Permanente and U.S. Veterans Administration to help minimize misdiagnosis.
Organizational Policy/Guidelines
Baglin TP, Cousins D, Keeling DM, et al. British journal of haematology. 2007;136(1):26-9.
The authors provide guidelines to help manage risks and ensure the safe administration of oral anticoagulant therapy in the United Kingdom.
by John G. DeVine, MD|
March 1, 2015
A man with suspected renal cell carcinoma seen on CT in the right kidney was transferred to another hospital for surgical management. The imaging was not sent with him, but hospital records, which incorrectly documented the tumor as being on the left side—were. The second hospital did not obtain repeat imaging, and the surgeon did not see the original CT prior to removing the wrong kidney.
Newspaper/Magazine Article
Moore G. Patient Saf Qual Healthc. November / December 2006.
The author provides strategies to enhance the value of medication reconciliation through the use of decision support tools and shares one hospital's experience with implementing such a program.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Patrick F. Fogarty, MD |
A hospitalized woman with multiple medical problems is diagnosed with heparin-induced thrombocytopenia (HIT) but is mistakenly exposed to heparin flushes during dialysis.
WebM&M Cases
John M. Oldham, MD |
A young woman with borderline personality disorder hospitalized following a suicide attempt is allowed to leave the hospital and attempts suicide again.
WebM&M Cases
Michael Astion, MD, PhD |
A man admitted to the hospital for elective surgery has blood drawn. Despite a policy for proper identification, the blood samples were all mislabeled with another patient's name. The error was discovered at the lab, and there was no harm to the patient.
This Month’s Perspectives
Interview
J. Bryan Sexton, PhD, MA, is Assistant Professor, Department of Anesthesiology and Critical Care Medicine, at the Johns Hopkins University School of Medicine. Trained as a social psychologist, he has become one of the world's foremost authorities on the role of culture in patient safety. He developed the widely used Safety Attitudes Questionnaire and is one of the lead investigators of the Michigan Keystone ICU project, which aims to change practice and culture in intensive care units (ICUs) throughout the state. His research examines the connections between attitudes, behaviors, and outcomes in high-risk team environments, particularly aviation and medicine. We asked him to speak with us about safety climate surveys and efforts to change safety culture.
Perspective
Timothy J. Hoff, PhD |
Safety cultures are the holy grail in any risky industry. Like all holy grails, they can never be fully realized. This is particularly the case in health care. Why? Health care organizations struggle with too many competing demands to make safety the only...
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