March 17, 2010 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.
Kaushal R, Kern LM, Barrón Y, et al. J Gen Intern Med. 2010;25(6).
Few ambulatory practices use electronic health records (EHRs) in any form, and even those that do generally do not utilize advanced functions such as computerized provider order entry (CPOE). Cost and a lack of high-quality efficacy data are frequently cited as barriers to EHR and CPOE adoption. This controlled trial compared prescribing error rates in 15 ambulatory practices that adopted a commercial e-prescribing system to those of 15 practices that continued using standard paper prescriptions, and found a striking reduction in prescribing errors in the CPOE group. Such safety data may help make the business case for adopting CPOE in the ambulatory setting. A Patient Safety Primer discusses medication errors and other common safety problems in ambulatory care.
Miller JL, Johnson PN, Harrison DL, et al. Ann Pharmacother. 2010;44(1):35-42.
Overweight children were at a significantly increased risk of medication underdosing compared with children of age- and sex-appropriate weight.
Apker J, Mallak LA, Applegate B, et al. Ann Emerg Med. 2010;55(2):161-70.
This study reports on the development of a tool to assess the content and structure of handoff communications between emergency physicians and hospitalists. The authors found that the handoff communication was mostly "one-way," consisting primarily of information exchange without interactive questions and answers.
France DJ, Greevy RA, Liu X, et al. Med Care. 2010;48(3):279-84.
This study found an overall positive safety culture in intensive care units, based on a survey of providers at all levels.
Singh H, Thomas EJ, Sittig DF, et al. Am J Med. 2010;123(3):238-44.
Unreliable test result management systems are a common problem in ambulatory care, and failure (or inability) to promptly follow up abnormal test results may lead to diagnostic errors and other safety problems. Automated alerts within electronic health records should minimize such problems. However, this study conducted in Veterans Affairs clinics found that 1 in 10 alerts for abnormal laboratory test results went unread by providers, and a large proportion of those patients did not receive timely clinical follow-up. The investigators found similar results when analyzing follow-up of alerts for abnormal imaging results. "Alert fatigue" is one possible explanation for these findings.
Dickinson A, McCall E, Twomey B, et al. J Clin Nurs. 2010;19(5-6).
This focus group study identified problems with the recommended practice of double checking high-risk medications before administration.
Smith AF, Boult M, Woods I, et al. Qual Saf Health Care. 2010;19(1):69-73.
Safety improvement efforts are often guided by error data that are gathered retrospectively (e.g., incident reports). This study reports on a collaborative process used to prospectively identify safety hazards and improvement strategies in perioperative care.
Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25(5):441-447.
Discrepancies in patients' medications at the time of hospital admission are common. Performed at an academic medical center, this cohort study used a pharmacist-led medication reconciliation process to determine a "gold standard" medication list for newly admitted patients, identify discrepancies between patients' medication lists and the medications ordered by admitting physicians, and investigate risk factors for preventable medication errors. More than one-third of patients had at least one discrepancy, with elderly patients and patients with more complex medication regimens being at higher risk—factors also documented in prior research. Patients who presented their own medication list or pill bottles were at reduced risk. The medication reconciliation process used in this study is available as an online toolkit.
Kahn MG, Ranade D. J Am Med Inform Assoc. 2010;17(2):185-91.
Trigger tools are used to screen for patient safety events and are also used to calculate rates of certain safety problems (such as adverse drug events). This study found that the rate of a trigger tool–based drug safety quality measure varied widely depending on the specific data source used to calculate the rate.
Ferranti JM, Langman MK, Tanaka D, et al. J Am Med Inform Assoc. 2010;17(2):136-43.
This article explains how health information technologies can enhance understanding of and contextualize data rather than just collect it. Case studies demonstrate how hospitals can use this approach to improve safety and quality.
Commentary
Pettker CM, Funai EF. JAMA. 2010;303(10):977-8.
This brief commentary discusses the relationship between blame, accountability, and just culture, as well as support for clinicians involved in errors.
MacCourt D, Bernstein J. Am J Law Med. 2009;35(4):505-61.
This article discusses the culture of blame in medicine, which keeps errors hidden and leaves injured parties uncompensated. To facilitate recognition of and compensation for harm, the authors recommend a system that includes limited liability, transparency, and arbitration.
Martyn C. BMJ. 2010;340(mar03 3).
This essay relates what health care systems can learn from industry about making the work environment safer and more reliable.
Carpenter KB, Duevel MA, Lee PW, et al. Qual Saf Health Care. 2010;19(1):48-54.
Providing background on the World Alliance for Patient Safety, this article reviews literature on patient safety methods in developing countries.
Jha AK, Prasopa-Plaizier N, Larizgoitia I, et al. Qual Saf Health Care. 2010;19(1):42-7.
Complementing a concurrent review and previous report on research goals, this article describes work of the WHO World Alliance for Patient Safety to identify research topics to support patient safety improvement efforts worldwide.
No results.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; March 2010. Report No. OEI-06-08-00221.
This report examined five methods of identifying adverse events that harmed hospitalized patients. Findings note that physician and nurse reviews were highly effective in discovering problems but that incident reports were not as useful. The document provides numerous recommendations to improve screening for adverse events.
Ryan K, Levit K, Davis PH. HCUP Statistical Brief #87. Rockville, MD: Agency for Healthcare Research and Quality; March 2010.
Using data from the Healthcare Cost and Utilization Project, this report analyzed characteristics of weekend hospital stays and found that patients experienced delays in receiving care compared with patients admitted during the week.
Government Resource
PA-PSRS Patient Saf Advis. March 2010;7:9-17.
This article analyzed 2685 event reports involving insulin and found that the most common error types were drug omission, wrong-dose, and wrong-drug errors.
Special or Theme Issue
J Patient Saf. 2010;6(1):1-47, 52-56.
Focusing on a leadership perspective, this special issue contains numerous narrative articles regarding the National Quality Forum (NQF) Safe Practices for Better Healthcare.
Book/Report
Classic
Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; March 2010.
Medical schools face an urgent need to transform their curricula to emphasize patient safety, according to this report from the Lucian Leape Institute at the National Patient Safety Foundation. Based on a roundtable discussion among leading medical education and patient safety experts, this report concludes that the traditional curricular focus on medical knowledge and technical expertise must shift to incorporate key concepts in systems analysis and patient-centered care. The piece includes specific recommendations for medical school and academic medical center leadership to develop rigorous safety curricula and evaluation methods. The report also emphasizes the importance of a culture of safety in teaching hospitals, stressing that unprofessional behavior and authority gradients prevent students from reporting and learning from errors.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Gail B. Slap, MD, MSc |
An overweight teenaged girl came to the pediatrics clinic for routine follow-up of her type 2 diabetes, complaining of nonspecific, intermittent abdominal pain and worsening acne. The physician prescribed topical acne cream and increased her diabetes medications. The next day, an obstetrician notified the pediatrician that this patient had delivered a healthy infant via Caesarian section overnight.
WebM&M Cases
Robert J. Weber, PharmD, MS |
An elderly woman presented to the emergency department following a hip fracture. Although the patient's medication bottles were used to generate a medication list, one of the dosages was transcribed incorrectly. Because the patient then received four times her regular dose, her surgery was delayed due to cardiac side effects.
WebM&M Cases
Manish K. Sethi, MD |
Over the course of 2 years, a patient who frequently came to the emergency department complaining of abdominal pain underwent 12 CT scans of the abdomen and pelvis. All of them were completely normal.
This Month’s Perspectives
Interview
Thomas J. Nasca, MD, is the executive director and chief executive officer of the Accreditation Council for Graduate Medical Education (ACGME). Prior to joining the ACGME in 2007, Dr. Nasca, a nephrologist, was dean of Jefferson Medical College and Senior Vice President for Academic Affairs of Thomas Jefferson University. We asked him to speak with us about the role of the ACGME in patient safety.
Perspective
Arpana R. Vidyarthi, MD; Robert B. Baron, MD, MS |
Clear health communication is increasingly recognized as essential for promoting patient safety. Yet according to a recent Joint Commission report, What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety, communication problems among health care providers, patients, and families are common and a leading root cause of adverse outcomes.(1) Addressing health literacy—the capacity of individuals to obtain, process, and understand basic health information and services needed to make appropriate health decisions—has become a primary objective for many health systems in order to protect patients from harm.
