August 15, 2012 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.
Davis MM, Devoe M, Kansagara D, et al. J Gen Intern Med. 2012;27(12):1649-56.
Health care providers and administrators expressed considerable frustration with existing hospital discharge processes, noting fragmented systems of care, poor interdisciplinary communication, and lack of a standardized approach. These problems were felt to be responsible for preventable adverse events after discharge.
Gargiulo DA, Sheridan J, Webster CS, et al. BMJ Qual Saf. 2012;21(10):826-34.
Anesthesiologists were observed to violate sterile technique frequently when administering medications in a simulated setting. These protocol violations could contribute to hospital-acquired infections.
Gellad WF, Good CB, Amuan ME, et al. J Am Geriatr Soc. 2012;60(7):1222-9.
Substantial variation was found between Veterans Affairs hospitals in the frequency of prescribing inappropriate medications for elderly patients.
Shebl NA, Franklin BD, Barber N. BMC Health Serv Res. 2012;12:150.
This study casts doubt on the validity and reliability of failure mode and effect analysis, a commonly used tool to prospectively identify safety hazards.
Howie WO, Dutton RP. AANA J. 2012;80(3):179-184.
Implementing a standardized checklist resulted in a significant reduction in the proportion of trauma patients who could not be successfully liberated from mechanical ventilation.
Cimiotti JP, Aiken LH, Sloane DM, et al. Am J Infect Control. 2012;40(6):486-490.
The critical role that nurses play in ensuring patient safety can be compromised by excess workload. A large body of literature has linked higher patient-to-nurse ratios to a variety of preventable complications and even increased inpatient mortality. However, it is not clear whether high nursing workload alone can impair patient safety, or if overall working conditions for nurses also plays a role in safety. This study, which examined the association between hospital-acquired infections, nurse staffing, and burnout among nurses found that the number of patients per nurse did not entirely predict safety problems. On the other hand, after controlling for hospital and patient characteristics, the investigators found that increased rates of burnout among nurses was significantly associated with a higher risk of hospital-acquired infections. The complex issue of nurse staffing and workload is discussed in this AHRQ WebM&M commentary.
Sherbino J, Dore KL, Wood TJ, et al. Acad Med. 2012;87(6):785-791.
Cognitive shortcuts, or heuristics, are often used by clinicians to make diagnoses. Prior research has shown that inappropriate use of heuristics can lead to diagnostic errors. However, this simulation study found that diagnoses made rapidly were also more accurate, even when controlling for clinicians' baseline knowledge.
Pinto A, Brunese L, Pinto F, et al. Semin Ultrasound CT MR. 2012;33(4):275-9.
This commentary discusses common errors in radiology and describes the differences between adverse outcomes and malpractice.
Dresser S. J Nurs Adm. 2012;42(7-8):361-368.
This commentary discusses nursing surveillance and how it can help enhance monitoring of patient conditions to address failure to rescue as well as other care delays.
Olson R, Garite TJ, Fishman A, et al. Am J Obstet Gynecol. 2012;207(2).
This review discusses how the obstetric-gynecologic hospitalist model can help reduce physician fatigue and delays in care.
Morello RT, Lowthian JA, Barker AL, et al. BMJ Qual Saf. 2013;22(1):11-8.
Developing a culture of safety is essential for creating high reliability organizations in health care. Although safety culture can be measured and compared across institutions, the methods organizations should use to improve safety culture have yet to be defined. This systematic review, however, found evidence (and limited evidence at that) to support only two strategies to improve safety culture: executive walk rounds and unit-based safety programs. As many institutions are embarking on efforts to develop safety culture, this review highlights the need for more rigorous evaluation and broader dissemination of such efforts.
Seys D, Scott SD, Wu AW, et al. Int J Nurs Stud. 2013;50(5):678-687.
Clinicians who are involved in a medical error are at increased risk for psychological complications and burnout; this phenomenon has resulted in clinicians who are involved in errors being called second victims. This review identified several strategies that organizations can use to support second victims, both at an individual and organizational level. An important part of supporting second victims appears to be providing immediate access to assistance, as in a second victim rapid response team. The effects of errors on health care providers are discussed in this AHRQ WebM&M perspective.
Medical Product Safety Network. Silver Spring, MD; US Food and Drug Administration. November 19, 2008.
This Web site provides information about tubing misconnections and how to prevent them.
Hernandez LM; Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine. Washington, DC: The National Academies Press; 2012. ISBN: 9780309256810.
This report details the results of a workshop on health literacy in health care organizations.
Newspaper/Magazine Article
Terhune C.
This newspaper article reports on an incident during which dozens of hospitals lost access to electronic medical records (EMRs) and discusses risks associated with EMR systems.
Kohn LT. Washington, DC: United States Government Accountability Office; July 2012. Publication GAO-12-712.
This report examines unsafe injection practices in ambulatory care and recommends strengthening existing initiatives to drive improvement.
Sentinel Event Alerts
Sentinel Event Alert. 2012;49:1-5.
Opioid pain medications are considered high-risk medications due to the potential for respiratory depression and other adverse effects. Because these medications are frequently used to treat acute pain in the hospital, opioids account for a disproportionate share of preventable adverse drug events. This sentinel event alert, issued by The Joint Commission to highlight particularly important safety issues, calls for hospitals to implement standardized methods to assess and monitor acute pain, ensure education for clinicians on appropriate opioid usage, and use information technology to support safe opioid prescribing. A serious case of opioid overdose is discussed in this AHRQ WebM&M commentary.
Note: This alert has been retired effective February 2019. Please refer to the information link below for further details.
Newspaper/Magazine Article
Hartocollis A.
This newspaper article reports on the missteps that contributed to the death of a young woman after she was hospitalized in an incident reminiscent of Libby Zion.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Carlton R. Moore, MD, MS |
Drawn on a Thursday, basic labs for a 10-year-old girl came back over the weekend showing a high glucose level, but neither the covering physician nor the primary pediatrician saw the results until the patient's mother called on Monday. Upon return to the clinic for follow-up, the child's glucose level was dangerously high and urinalysis showed early signs of diabetic ketoacidosis.
WebM&M Cases
Matt M. Kurrek, MD, and Rebecca S. Twersky, MD, MPH |
Following spinal anesthesia for an outpatient procedure, a patient is discharged and instructed to take sitz baths with tepid water. The patient misunderstood the instructions, using scalding water instead, and residual anesthesia blunted his response to the hot water.
WebM&M Cases
Rachel Sorokin, MD, and Mitchell Conn, MD, MBA |
Admitted for treatment of congestive heart failure, an elderly man with a percutaneously placed gastric feeding tube began to have liters of watery stool daily. A tube check revealed that the tip of the feeding tube was in the colon and not the stomach.
This Month’s Perspectives
Interview
An expert on patient safety in nursing homes, Dr. Castle is a Professor at the University of Pittsburgh in the Department of Health Policy and Management.
Perspective
Jerry Gurwitz, MD |
This piece, written by a national leader in safe use of medications in elderly patients, discusses strategies for improving the quality and safety of medication use in the nursing home setting.
