August 21, 2019 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.
Simpkin AL, Murphy Z, Armstrong KA. Diagnosis (Berl). 2019;6(3):269-276.
Whether or not word selection during handoffs affects clinician anxiety and diagnostic uncertainty remains unknown. In this study involving medical students, researchers found that use of the word "hypothesis" compared to the word "diagnosis" when describing a hypothetical handoff from the emergency department to the inpatient setting was associated with increased self-reported anxiety due to uncertainty.
Pedersen CA, Schneider PJ, Ganio MC, et al. Am J Health Syst Pharm. 2019;76(14):1038-1058.
This article describes results from the 2018 American Society of Health-System Pharmacists national survey regarding inpatient pharmacy practice. The authors report several trends including the development of opioid stewardship programs with pharmacist involvement and a higher percentage of hospitals with pharmacists working across a greater variety of clinical areas.
Dinsdale E, Hannigan A, O’Connor R, et al. Fam Pract. 2019;17(1):63-68.
Clear communication between primary care physicians and the providers to whom they refer patients has important implications for achieving accurate diagnosis and appropriate treatment plans for patients. In this observational study, researchers included 6603 patients from 68 general medical practices in Ireland, randomly selecting 100 patients from each practice and excluding patients without complete records. They analyzed referral documentation and responses received from subspecialists as well as discharge summaries from hospitalizations over a 2-year period, compared with established national standards. Although 82% of referral letters included current medications, only 30% of response letters and discharge summaries contained medication changes and 33% had medication lists. The authors conclude that significant communication gaps exist between primary and secondary care and that further research is needed to understand how to address them. A past PSNet perspective discussed challenges associated with care transitions.
Chaitoff A, Strong AT, Bauer SR, et al. J Surg Educ. 2019;76(6):1612-1621.
In this retrospective cohort study, researchers analyzed 571,811 medication orders placed by 169 general surgery residents over approximately 6.5 years. Pharmacist intervention was required for 4.2% of orders, and about 67% of these represented either duplicate therapies or incorrect renal dosing. They found a higher odds of error in the intensive care unit and early in the academic year. The authors conclude that their findings represent potential targets for educational interventions aimed at reducing medication ordering errors among trainees.
Pandya C, Clarke T, Scarsella E, et al. J Oncol Pract. 2019;15(5):e480-e489.
Care transitions and handoffs represent a vulnerable time for patients, as failure to communicate important clinical information may occur with the potential for harm. In this pre–post study, researchers found that implementation of an electronic health record tool designed to improve the handoff between oncology clinic and infusion nurses was associated with a reduction in medication errors, shorter average patient waiting time, and better communication between nurses.
Shepherd L, LaDonna KA, Cristancho SM, et al. Acad Med. 2019;94(8):1157-1163.
Although medical errors present opportunities for learning, less is known about how the emotions providers experience after an error affect their perceptions of learning. In this study, researchers interviewed 19 Canadian providers regarding their experiences with learning from mistakes. They found that memories of mistakes from training seemed to stand out, and participants expressed feeling both responsible for mistakes and blamed for them. Both cultural and individual factors facilitated and deterred learning from these experiences. Positive experiences with mentorship and peer support were identified as helpful. Experiences with formal review processes and rounds were mixed. The authors conclude that using a learning culture perspective that acknowledges blame and responsibility can facilitate learning from mistakes. A past PSNet interview discussed the emotional toll of errors on physicians.
Segal G, Segev A, Brom A, et al. J Am Med Inform Assoc. 2019;26(12):1560-1565.
Alerts designed to prevent inappropriate prescribing of medications are frequently overridden and contribute to alert fatigue. This study describes the use of machine learning to improve the clinical relevance of medication error alerts in the inpatient setting.
Soncrant C, Neily J, Sum-Ping SJT, et al. J Patient Saf. 2021;17(4):e343-e349.
The authors describe the results of a survey of anesthesiology chiefs designed to understand their perceptions of the Veterans Health Administration efforts surrounding the lessons learned process for adverse events occurring in anesthesia. Of participants who had been aware of lessons learned, 90% shared them with staff and 75% described changing or reinforcing safety behaviors.
Sherwood R, Bismark M. BMJ Qual Saf. 2020;29(2):113-121.
Confidential skill assessments have been recommended as a strategy to ensure competence among aging surgeons. In this qualitative study, the authors describe opinions from 52 experts on how to manage potential concerns associated with aging surgeons.
Forster AJ, Hamilton S, Hayes T, et al. Healthc Manage Forum. 2019;32(5):266-271.
The just culture paradigm shifts the response to error from a retrospective focus on blame to the system that contributed to the incident. This commentary describes one hospital's strategic and operational approach to just culture development and the results of the initiative.
Urbach DR, Dimick JB, Haynes AB, et al. BMJ. 2019;366:l4700.
Checklists are a popular yet controversial strategy for improving the safety of frontline care. The authors in this commentary debate the weaknesses and strengths of checklists through a discussion of the evidence.
Singh H, Khanna A, Spitzmueller C, et al. Diagnosis (Berl). 2019;6(4):315-323.
This commentary discusses the revision of a structured tool for physician review of medical records to assess if a diagnostic error took place. The authors provide rationale for the revision of the tool, outline the changes made, and offer recommendations for use of the tool.
Wiebe N, Varela LO, Niven DJ, et al. J Am Med Inform Assoc. 2019;26(11):1389-1400.
This systematic review found that while interventions designed to improve inpatient documentation within electronic health records (EHRs) are highly varied, education and EHR reporting systems seem to be more effective in improving electronic documentation for hospitalized patients than other efforts.
Lyman B, Jacobs JD, Hammond EL, et al. J Adv Nurs. 2019;75(11):2352-2377.
Organizations are encouraged to learn from failures. This review synthesizes the research on organizational learning in hospitals, including contextual factors that affect it, how such learning occurs, and improvements implemented as a result.
Given BA. Semin Oncol Nurs. 2019;35(4):374-379.
Cancer patients often rely on family members or paid caregivers to assist with care maintenance at home, such as taking medications and mobility support. This review highlights common safety gaps in home cancer care. The authors suggest that nurses can help assess caregiver knowledge and provide education to address safety issues.
S Miller C, Scott SD, Beck M. J Patient Saf Risk Manag. 2019;24(3):108-117.
The second victim effect refers to the emotional distress health care providers may experience after an adverse event or error. This systematic review found that mindfulness interventions have the potential to reduce stress and burnout among physicians. The authors suggest that further research regarding the impact of mindfulness on the second victim effect is needed.
No results.
Special or Theme Issue
Main EK, Fowler JM, Gabbe SG, eds. Clin Obstet Gynecol. 2019;62:vii-xii,403-626.
Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. Articles in this special issue discuss how to address burnout and support resilience in obstetrics and gynecology care. Tactics covered include bundles, checklists, and collaboratives.
Zheng K, Westbrook J, Kannampallil TG, Patel VL, eds. Springer International Publishing; 2019. ISBN: 9783030169152.
Challenges associated with electronic health record design and implementation contribute to interruptions, workarounds, and information overload. This book explores topics relevant to workflow disruptions that can degrade safe practice. The chapters review strategies such as data analysis techniques and human factors engineering to generate improvements.
Newspaper/Magazine Article
Panner M. Forbes. August 12, 2019.
Diagnostic errors can result in harm across the spectrum of practice. Discussing cognitive and system factors in radiology that contribute to diagnostic mistakes, this magazine article recommends ways to reduce risk of errors, including peer review of practice, structured reporting, and artificial intelligence–enabled decision support.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Mythili P. Pathipati, MD, and James M. Richter, MD |
An elderly man had iron deficiency anemia with progressively falling hemoglobin levels for nearly 2 years. Although during that time he underwent an upper endoscopy, capsule endoscopy, and repeat upper endoscopy and received multiple infusions of iron and blood, his primary physician maintained that he didn't need a repeat colonoscopy despite his anemia because his previous colonoscopy was negative. The patient ultimately presented to the emergency department with a bowel obstruction, was diagnosed with colon cancer, and underwent surgery to resect the mass.
WebM&M Cases
Michael J. Barry, MD, and Marc B. Garnick, MD |
Referred to urology for a 5-year history of progressive urinary frequency, nocturnal urination, and difficulty initiating a stream, a man had been reluctant to seek care for his symptoms because his father had a "miserable" experience with treatment for the same condition. A physician assistant saw him at that first visit and ordered a PSA test (despite the patient's expressed views against PSA testing) and cystoscopy (without explaining why it was needed), and urged the patient to self-catheterize (without any instructions on how to do so). The patient elected not to follow up with the tests because of this negative interaction. Ten weeks later, he sought care from a nurse practitioner at his primary care provider's office where his blood pressure and creatinine levels were found to be markedly elevated, 2L of urine were drained via catheter, and he was admitted to the hospital for renal failure.
WebM&M Cases
Yi Lu, MD, PhD, and Douglas Salvador, MD, MPH |
A woman with a history of prior spine surgery presented to the emergency department with progressive low back pain. An MRI scan of T11–S1 showed lumbar degenerative joint disease and a small L5–S1 disc herniation. She was referred for physical therapy and prescribed muscle relaxant, non-steroidal anti-inflammatories, and pain relievers. Ten days later, she presented to a community hospital with fever, inability to walk, and numbness from the waist down. Her white blood cell count was greater than 30,000 and she was found to be in acute renal and liver failure. She was transferred to a neurosurgery service at an academic hospital when an MRI revealed a T6–T10 thoracic epidural abscess.
This Month’s Perspectives
Interview
Dr. Smith is Chief Faculty Practices Officer for UCSF Health and a family medicine physician. Over the past 3–4 years, the health system has implemented a robust program using medical scribes in the outpatient setting. We spoke with her about her experience implementing this program, including the benefits and some of the potential patient safety ramifications.
Perspective
Deborah Woodcock, MS, MBA; Robby Bergstrom |
This piece explores the role medical scribes play in health care, how to implement and evaluate a scribe program, and recommendations to reduce variations in scribe practice.
