Email Updates
August 31, 2022 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.
This Week’s Featured Articles
Ahsani-Estahbanati E, Sergeevich Gordeev V, Doshmangir L. Front Med (Lausanne). 2022;9:875426.
Hospital-acquired conditions impact not only patient morbidity and mortality, but are also a significant financial burden. This review identified eight categories of hospital-acquired conditions (i.e., overall medical error, medication error, diagnostic error, patient falls, healthcare-associated infections, transfusion and testing errors, surgical error, and patient suicide) and more than 100 proposed interventions addressing those conditions.
Kaplan HJ, Spiera ZC, Feldman DL, et al. J Am Coll Surg. 2022;235(3):494-499.
Unintentionally retained surgical items (RSI) can have a devastating impact on patient health and safety. One method to reduce the incidence of RSI is radiofrequency (RF) detection. Nearly one million operations in New York state were analyzed for the rate of RSI before and after the use of RF was required and simultaneous TeamSTEPPS training was provided. The incidence of RF-detectable items was significantly reduced, but the rate of non-RF-detectable items was not.
Plunkett A, Plunkett E. Paediatr Anaesth. 2022;32(11):1223-1229.
Safety-I focuses on identifying factors that contribute to incidents or errors. Safety-II seeks to understand and learn from the many cases where things go right, including ordinary events, and emphasizes adjustments and adaptations to achieve safe outcomes. This commentary describes Safety-II and complementary positive strategies of patient safety, such as exnovation, appreciative inquiry, learning from excellence, and positive deviance.
Thiele L, Flabouris A, Thompson C. PLoS ONE. 2022;17(6):e0269921.
Patient and family engagement is essential for safe healthcare. This single-site study found that while most clinicians perceived that patients and families are able to recognize clinical deterioration, clinicians expressed less favorable perceptions towards escalation processes when patients or families have concerns about clinical deterioration.
van Dalen ASHM, Jung JJ, Nieveen van Dijkum EJM, et al. J Patient Saf. 2022;18(6):617-623.
Leveraging lessons learned in aviation, patient safety researchers have begun exploring the use of medical data recorders (i.e., “black boxes”) to identify errors and threats to patient safety. This cross-sectional study found that a medical data recorder identified an average of 53 safety threats or resilience support events among 35 standard laparoscopic procedures. These events primarily involved communication failures, poor teamwork, and situational awareness failures.
Gauthier-Wetzel HE. Comput Inform Nurs. 2022;40(6):382-388.
Barcode medication administration (BCMA) has been promoted as an effective method for reducing medication administration errors. In the emergency department of one Veterans Affairs Medical Center, medication error rates decreased by nearly 11% following introduction of BCMA technology. However, unsafe workarounds were also identified, which may limit the overall safety of BCMA.
Lester CA, Flynn AJ, Marshall VD, et al. J Am Med Inform Assoc. 2022;29(9):1471-1479.
Although e-prescribing has improved the safety of medication ordering, preventable errors persist. This study analyzed product descriptions (ingredient, strength, dose form) of more than 10 million e-prescriptions. Results show a wide variety in the way drug product descriptions are entered into e-prescription programs (e.g., 707 variants for “oral tablet” such as tablet, tab, po tab). Poor standardization of terminology in e-prescription programs can lead to incorrect medication order and patient confusion.
Barclay ME, Dixon-Woods M, Lyratzopoulos G. JAMA Health Forum. 2022;3(5):e221006.
The Centers for Medicare & Medicaid Services (CMS) provides individual and composite quality and safety ratings (i.e., star ratings) for hospitals and other healthcare facilities on its Care Compare website. This study evaluated three alternative methods for rating facilities and compared them to the CMS star ratings. Hospitals were frequently assigned a different star rating using the alternate methods, typically between adjacent star categories.
Waldron J, Denisiuk M, Sharma R, et al. Injury. 2022;53(6):2053-2059.
Increases in clinician workload can contribute to burnout. This study explored seasonal variation in workload in an orthopedic trauma service at one Level 1 trauma center. Findings indicate that workload was highest in the summer months and correlated with resident sleepiness scores. The study team also found that patient safety events were highest during the summer, but these were not correlated with increased workload.
van Baarle E, Hartman L, Rooijakkers S, et al. BMC Health Serv Res. 2022;22(1):1035.
A just culture in healthcare balances organizational and individual responsibility and accountability when medical errors occur. This qualitative study including five healthcare organizations in the Netherlands concluded that open communication and emotional responses are important components of just culture. Researchers also identified several challenges in fostering a just culture, including how individual accountability is addressed and how to combine transparency with patient and clinician privacy.
Kandaswamy S, Grimes J, Hoffman D, et al. J Patient Saf. 2022;18(5):430-434.
Despite widespread implementation of computerized provider order entry (CPOE) for medication ordering, some orders may be submitted wholly or in part using the free-text field. This study analyzed CPOE orders that included medication information in the free text field. High-risk medications (e.g., insulin, heparin) were frequently mentioned and the most common expected action was to discontinue. Despite using the same CPOE software, there were wide variations between the six included hospitals in the rates of orders in free text and the types of medications mentioned.
Kaplan HJ, Spiera ZC, Feldman DL, et al. J Am Coll Surg. 2022;235(3):494-499.
Unintentionally retained surgical items (RSI) can have a devastating impact on patient health and safety. One method to reduce the incidence of RSI is radiofrequency (RF) detection. Nearly one million operations in New York state were analyzed for the rate of RSI before and after the use of RF was required and simultaneous TeamSTEPPS training was provided. The incidence of RF-detectable items was significantly reduced, but the rate of non-RF-detectable items was not.
Kosydar-Bochenek J, Krupa S, Religa D, et al. Int J Environ Res Public Health. 2022;19(15):9712.
A positive safety climate can improve patient safety and worker wellbeing. The Safety Attitudes Questionnaire (SAQ) was distributed to physicians, nurses, and paramedics in five European countries to assess and compare safety climate between professional roles, countries, and years of healthcare experience. All three groups showed positive attitudes towards patient safety, stress recognition, and job satisfaction; however, overall scores were low.
Schnipper JL. Ann Intern Med. 2022;175(8):ho2-ho3.
Medication reconciliation is a primary method for improving the safety of medication administration in acute care. This essay highlights how individual hospitalists can improve medication reconciliation both at the practice and organizational level. Areas of influence discussed include medication history completeness and health information technology design.
Stockwell DC, Kayes DC, Thomas EJ. J Patient Saf. 2022;18(5):e877-e882.
Striving for “zero harm” in healthcare has been advocated as a patient safety goal. In this article, the authors discuss the unintended consequences of “zero harm” goals and provide an alternative approach emphasizing learning and resilience goals (leveled-target goal setting, equal emphasis goals, data-driven learning, and developmental) rather than performance goals.
Plunkett A, Plunkett E. Paediatr Anaesth. 2022;32(11):1223-1229.
Safety-I focuses on identifying factors that contribute to incidents or errors. Safety-II seeks to understand and learn from the many cases where things go right, including ordinary events, and emphasizes adjustments and adaptations to achieve safe outcomes. This commentary describes Safety-II and complementary positive strategies of patient safety, such as exnovation, appreciative inquiry, learning from excellence, and positive deviance.
Review
Raffel K, Ranji S. UpToDate. February 8, 2024.
Diagnostic mistakes are common contributors to preventable patient harm. This review highlights primary areas of diagnostic error concerns (vascular events, infections, and cancers) and summarizes evidence related to their measurement and error reduction.
Randles MA. Drugs Aging. 2022;39(8):597-606.
Potentially inappropriate prescribing (PIP) among older adults is common and can result in medication-related harm. This narrative review summarizes the evidence on the association between potential frailty and PIP. The authors identified several challenges in measuring and reducing the risks of PIP, including the need for user-friendly methods to rapidly and accurately identify frailty in older adults at risk of PIP.
Ahsani-Estahbanati E, Sergeevich Gordeev V, Doshmangir L. Front Med (Lausanne). 2022;9:875426.
Hospital-acquired conditions impact not only patient morbidity and mortality, but are also a significant financial burden. This review identified eight categories of hospital-acquired conditions (i.e., overall medical error, medication error, diagnostic error, patient falls, healthcare-associated infections, transfusion and testing errors, surgical error, and patient suicide) and more than 100 proposed interventions addressing those conditions.
Wallace W, Chan C, Chidambaram S, et al. NPJ Digit Med. 2022;5(1).
Patient use of digital and online symptom checkers is increasing, but formal validation of these tools is lacking. This systematic review identified ten studies assessing symptom checkers evaluating a variety of conditions, including infectious diseases and ophthalmic conditions. The authors concluded that the diagnostic and triage accuracy of symptom checkers varies and has low accuracy.
No results.
Schulson LB, Thomas AD, Tsuei J, et al. Santa Monica, CA: RAND Corporation; 2022
Clinical leaders have unique viewpoints on front-line care challenges. This report includes results of an environmental scan and expert interviews that examined how racism, bias, and patient safety intertwine to affect incident reporting, safety culture, and adverse event data collection.
Special or Theme Issue
AMA J Ethics. 2022;24(8):e715-e816.
Health inequity is recent expansion in the patient safety canon. This special issue examines poor access, quality of care, and health status as contributors to patient harm. Articles discuss race, gender, and ethnicity as factors generating unsafe experiences for patients.
National Institutes of Health. August 11, 2022. RFA-HD-23-035.
Maternity care is increasingly being recognized as vulnerable to implicit biases and social inequities. This funding announcement aims to support initiatives that promote equity as a primary component of efforts to study preventable maternal harm in a variety of disadvantaged and ethnic populations. The application process is now closed.
London, England: NHS England; August 2022.
Effective response to medical error requires a comprehensive systemic and process-focused incident examination approach to ensure organizational learning. This framework will replace the current method used by the UK National Health Service (NHS) to support overarching patient safety strategic aims for the agency. The toolkit contains resources for organizations to explore the factors contributing to patient safety incidents and inform safety improvements.
This Month’s WebM&Ms
WebM&M Cases
Carla S. Martin, MSN, RN, CIC, CNL, NEA-BC, FACHE, Shannon K. Reese, BSN, RN, VABC, and Margaret Brown-McManus, MSN, RN, CNL |
This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services. During follow-up several days after discharge, the patient’s primary care provider noted that the PICC dressing was due to be changed and needed to be flushed, but the outpatient setting lacked the necessary supplies. An urgent referral to home health was placed, but the agency would be unable to attend to the patient for several days. The primary care provider changed the dressing, and the patient was referred to the emergency department for assessment. The commentary summarizes the risks of PICC lines, the role of infection prevention practices during the insertion and care of PICC lines, and the importance of patient education and skill assessment prior to discharge home with a PICC line.
WebM&M Cases
Samantha Brown, MD, John S. Rose, MD, and David K. Barnes, MD |
A 71-year-old man presented to a hospital-based orthopedic surgery clinic for a follow-up evaluation of his knee and complaints of pain and swelling in his right shoulder. His shoulder joint was found to be acutely inflamed and purulent fluid was aspirated from his shoulder. The patient was sent to the Emergency Department (ED) for suspected septic arthritis. Although the inpatient team was made aware of the incoming patient and admission orders were entered into the electronic health record (EHR) before ED arrival, ED staff were not informed of the incoming patient or the orthopedic surgeon’s plan for immediate admission. When the patient arrived, there were multiple patients in the ED waiting room and multiple boarding patients awaiting inpatient beds. The patient stayed in the ED hallway on “wall time” under the care of the Emergency Medical Services (EMS) personnel; no ED physician or nurse was assigned to evaluate or care for the patient because the transfer of care from EMS had not occurred. The patient was on wall time for at least 10 hours before any actions were taken by the ED before being admitted to the orthopedic inpatient service. The commentary discusses challenges associated with ED transfers and ED overcrowding, potential system-level solutions to the “wall time” problem, and the importance of closed-loop communication.
WebM&M Cases
Commentary by Jennifer Rosenthal, MD, MAS and Michelle Hamline, MD, PhD, MAS |
A 2-year-old girl presented to her pediatrician with a cough, runny nose, low grade fever and fatigue; a nasal swab for SARS-CoV-2 and influenza was negative and lung sounds were clear. The patient developed a fever and labored breathing and was taken to the Emergency Department (ED) before being admitted to the hospital. She developed respiratory distress and clinically worsened over time until she developed respiratory failure requiring air transportation to the pediatric intensive care unit at a children’s hospital. She was ultimately diagnosed with adenovirus after developing conjunctivitis and bronchiolitis. After 3 days of continuous monitoring and treatment in the PICU, the patient was alert, responsive, and hungry. She was taken off supplemental oxygen after about 24 more hours, transferred to a regular pediatric bed, and then discharged to outpatient follow-up care. The commentary addresses patient safety risks associated with pediatric interfacility transfers and strategies to mitigate preventable harms due to poor provider-provider communication, provider-family communication, and family engagement.
This Month’s Perspectives
Interview
Freya Spielberg MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social enterprise dedicated to improving the health of Individuals living in low-income housing in Washington, DC. Previously, as an Associate Professor at George Washington University, and at the University of Texas Dell Medical School, and School of Public Health, she developed a curriculum in Community Oriented Quality Improvement, to train the next generation of healthcare providers how to integrate population health into primary care to achieve the quintuple aim of better health outcomes, better patient experience, better provider experience, lower health care costs, and decreased health disparities. We spoke with her about her ongoing work in low-income communities to improve access to primary care and its impact on patient safety.
Interview
Jack Westfall, MD MPH, is a retired professor from the University of Colorado School of Medicine and Former Director of the Robert Graham Center. We spoke with him about the role of primary care in the health and well-being of individuals, the hallmarks of high quality primary care and opportunities of primary care providers to enhance or promote patient safety.
Stay Updated!
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. Sign up today to get weekly and monthly updates via emails!
