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October 19, 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
Aziz S, Barber J, Singh A, et al. J Hosp Med. 2022;17:880-887.
The introduction of new technology can have mixed consequences on staff workflows and patient safety. Focus groups of residents and nurses in a California children’s hospital sought to assess the advantages and shortcomings of secure text messaging systems (STMS) on teamwork, patient safety, and clinician well-being. Guidelines to reduce drawbacks are described.
Girotra S, Jones PG, Peberdy MA, et al. Circ Cardiovasc Qual Outcomes. 2022;15:e008901.
Rapid response teams (RRTs) have been implemented at hospitals worldwide, despite mixed results in their effectiveness. The aim of this study was to compare expected mortality rates with mortality rates following RRT implementation, adjusted for hospital case mix. Of 56 hospitals that participated in this project and had complete data, only four showed lower-than-expected mortality rates and two showed higher-than-expected mortality, suggesting RRT may not reduce mortality rates as much as earlier studies have reported.
Liu SI, Shikar M, Gante E, et al. Crit Care Nurse. 2022;42:33-43.
Lack of communication between providers can contribute to failure to rescue. Following a series of deaths due in part to not identifying clinical deterioration in a timely manner and/or not escalating care, this surgical intensive care unit (SICU) implemented an interdisciplinary quality improvement intervention. The intervention consisted of educating nurses on conditions necessitating escalation, multidisciplinary rounds with night staff, and an escalation document in the electronic health record (EHR).
Seys D, De Decker E, Waelkens H, et al. J Patient Saf. 2022;18:717-721.
Burnout and stress among healthcare workers can adversely impact patient safety. Using data from two cross-sectional surveys, this study found the COVID-19 pandemic had a larger impact on the mental health and well-being of healthcare workers compared to involvement in a patient safety incident. Negative psychological symptoms such as anxiety, sleep deprivation, and wanting to leave the profession were all significantly higher in COVID-19-related groups.
Van Wassenhove W, Foussard C, Dekker SWA, et al. Safety Sci. 2022;154:105835.
Proficient safety professionals are the cornerstone of effective patient safety programs. In this study, safety professionals provided insights about theoretical factors influencing the role of safety professionals in healthcare (e.g., legal regulation, organizational context, safety culture).
Schneider PJ, Pedersen CA, Ganio MC, et al. Am J Health Syst Pharm. 2022;79:1531-1550.
Pharmacists play a critical role in ensuring patient safety in both inpatient and outpatient settings. This article describes results from the 2021 American Society of Health-System Pharmacists national survey regarding inpatient pharmacy practice. Findings suggest that more pharmacists have prescribing authority and are increasingly recognized for their role in personalized drug therapy, but nearly three-quarters of respondents reported concerns about pharmacy staffing shortages.
Friebel R, Maynou L. Health Aff (Millwood). 2022;41:1486-1495.
Patients with developmental disabilities may be at higher risk for patient safety events in hospitals. This study used data from the Learning from Lives and Deaths (LeDeR) program in the UK to examine the prevalence of five avoidable in-hospital safety events. Compared to the general populations, patients with developmental disabilities experienced more patient safety incidents, longer length of stay and increased risk of death. Although the data did not include the causes of the incidents, the results support improving both inpatient and community care for persons with developmental disabilities.
Girotra S, Jones PG, Peberdy MA, et al. Circ Cardiovasc Qual Outcomes. 2022;15:e008901.
Rapid response teams (RRTs) have been implemented at hospitals worldwide, despite mixed results in their effectiveness. The aim of this study was to compare expected mortality rates with mortality rates following RRT implementation, adjusted for hospital case mix. Of 56 hospitals that participated in this project and had complete data, only four showed lower-than-expected mortality rates and two showed higher-than-expected mortality, suggesting RRT may not reduce mortality rates as much as earlier studies have reported.
Barrow E, Lear RA, Morbi A, et al. BMJ Qual Saf. 2023;32:383-393.
Patient and family engagement in safety is a priority for the UK’s National Health Service. This study asked patients in three hospital wards (geriatrics, elective surgery, maternity) how they conceptualize patient safety. Responses described what made them “feel safe” in their experiences with the organization, staff, the patients themselves, and family/carers.
Liu SI, Shikar M, Gante E, et al. Crit Care Nurse. 2022;42:33-43.
Lack of communication between providers can contribute to failure to rescue. Following a series of deaths due in part to not identifying clinical deterioration in a timely manner and/or not escalating care, this surgical intensive care unit (SICU) implemented an interdisciplinary quality improvement intervention. The intervention consisted of educating nurses on conditions necessitating escalation, multidisciplinary rounds with night staff, and an escalation document in the electronic health record (EHR).
Soled KRS, Dimant OE, Tanguay J, et al. BMC Health Serv Res. 2022;22:1134.
Transgender and gender-diverse people can face discriminatory behaviors when accessing health care services. This qualitative study explored clinician perspectives with regard to practicing transgender health care. Findings indicate that stigma, gatekeeping, and knowledge deficits are barriers to high-quality care delivery but respondents also highlighted strategies for successful care delivery, including mentorship and use of a person-centered approach to care.
Aziz S, Barber J, Singh A, et al. J Hosp Med. 2022;17:880-887.
The introduction of new technology can have mixed consequences on staff workflows and patient safety. Focus groups of residents and nurses in a California children’s hospital sought to assess the advantages and shortcomings of secure text messaging systems (STMS) on teamwork, patient safety, and clinician well-being. Guidelines to reduce drawbacks are described.
Dillon-Bleich K, Dolansky MA, Burant CJ, et al. J Nurs Care Qual. 2023;38:82-88.
Safety competencies are the knowledge, skills, and attitudes of healthcare providers to improve and ensure safe patient care. This study explored the interaction of nurses’ safety competencies with structural empowerment, systems thinking, level of education and certification. Results show systems thinking was positively correlated with safety competency; the authors recommend educators review the inclusion of safety competencies and systems thinking in academic curricula.
Dehmoobad Sharifabadi A, Clarkin C, Doja A. BMJ Open. 2022;12:e063104.
Several countries have resident duty hour (RDH) restrictions and there are numerous publications examining the impact of RDH on patient safety. This study used two online discussion forums (one primarily in the United States and the other in Canada) to assess resident perceptions of RDH. Themes included its impact on residents’ education and clinician well-being, and, worryingly, discussions of not reporting RDH violations.
Liu G, Chimowitz H, Isbell LM. Diagnosis (Berl). 2022;9:295-305.
Clinician’s emotions can influence their decision making, particularly with “difficult” patients. This article describes the role affect takes in clinical reasoning, including diagnosis. Strategies to counter the impact of emotional affect, such as emotional intelligence education, are presented.
Loving VA, Nolan C, Bessel M. Jt Comm J Qual Patient Saf. 2022;48:599-608.
The Safety-II perspective emphasizes improving patient safety by focusing on what goes right in healthcare, rather than on errors or what goes wrong (Safety-I). This article describes the development, implementation, and evaluation of an organizational, asset-based quality improvement tool to complement existing practices (such as peer review and incident reporting) and provide an additional avenue to identify best practices and successful quality improvement initiatives.
Commentary
Fleming EA. JAMA. 2022;328:1297-1298.
Honest apology is known to support healing from medical error for clinicians, patients, and families. This essay shares the experience of one physician who missed signs of a heart attack, mislabeling the condition as fatigue, who then apologized for the mistake. The author highlights how openness about the error was crucial in the continuation of the care relationship.
McCord JL, Lippincott CR, Abreu E, et al. Dimens Crit Care Nurs. 2022;41:347-356.
Workarounds can pose significant risks to patient safety. This systematic review including 13 studies found that nursing workarounds most often occurred due to challenges in using the electronic health record (EHR) system or during medication administration.
Organizational Policy/Guidelines
Joseph MM, Mahajan P, Snow SK, et al. Pediatrics. 2022;150:e2022059673.
Children with emergent care needs are often cared for in complex situations that can diminish safety. This joint policy statement updates preceding recommendations to enhance the safety of care to children presenting at the emergency department. It expands on the application of topics within a high-reliability framework focusing on leadership, managerial factors, and organizational factors that support safety culture and workforce empowerment to support safe emergency care for children.
Yeung AWK, Kletecka-Pulker M, Klager E, et al. J Patient Saf. 2022;18:e1116-e1123.
Legal and policy approaches are used to achieve sustained safety improvements. This review characterized the body of evidence regarding patient safety and its legal implications. Four approaches to improving safety were commonly covered in the literature – liability system reforms, new forms of regulation, increased transparency, and financial incentives.
No results.
Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Publication no. 22(23)-0047-2-EF.
Delayed, wrong, and missed diagnoses are common challenges for patients, families, and clinicians, yet physicians rarely receive feedback on their actions to enhance diagnostic decision making. This publication provides clinicians with tools to assess and calibrate diagnostic performance in support of individual learning and improvement.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 29, 2022.
Recalls of medications due to labeling errors are an established approach to minimize the potential for harm. This announcement highlights a labeling mistake with hypertension and antiplatelet medications that could result in dose omissions or bleeding risk.
Course Material/Curriculum
Farnborough, UK: Healthcare Safety Investigation Branch; 2022.
Distinct individual skills and organizational factors strengthen patient safety incident analysis efforts. This series of educational video modules encapsulates a curriculum for investigation teams associated with a national United Kingdom program. It covers topics such as safety science and analysis initiative strategy.
Multi-use Website
Norah Frye Centre for Disability Studies; Bristol, England.
People with a Learning Disability and autistic people (LeDeR) is a National Health Service-sponsored initiative that seeks to improve the care of learning disabled patients through examining what goes right and what goes wrong. The website includes a reporting function, patient-focused resources, and annual reports to distribute conclusions drawn from data analysis to inform improvements in the care of this patient population.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Brooks T Kuhn, MD, and Florence Chau-Etchepare, MD |
A 47-year-old man underwent a navigational bronchoscopy with transbronchial biospy under general anesthesia without complications. The patient was transferred to the post-acute care unit (PACU) for observation and a routine post-procedure chest x-ray (CXR). After the CXR was taken, the attending physician spoke to the patient and discussed his impressions, although he had not yet seen the CXR. He left the PACU without communicating with the bedside nurse, who was caring for other patients. The patient informed the nurse that the attending physician had no concerns. While preparing the patient for discharge, the nurse paged the fellow requesting discharge orders. The fellow assumed that the attending physician had reviewed the CXR and submitted the discharge orders as requested. Thirty minutes after the patient was discharged the radiologist called the care team to alert them to the finding of pneumothorax on the post-procedure CXR. The commentary summarizes complications associated with bronchoscopy and strategies to improve perioperative safety.
WebM&M Cases
Spotlight Case
Shushmita M Ahmed, MD, and Mohamed Ali, MD |
A 49-year-old woman presented to an Emergency Department (ED) with abdominal pain nine hours after discharge following outpatient laparoscopic left oophorectomy. The left oophorectomy procedure involved an umbilical port placed using an Optiport visual trocar, a suprapubic port, and two additional ports laterally. The operative note mentioned no visible injury upon entry into the abdominal cavity, but there were extensive adhesions in the pelvis. Nine hours after discharge, the patient presented to another hospital due to increasing pain, nausea, and fever. The patient underwent a laparotomy and the surgical team found fecal contamination upon entry into the peritoneal cavity; the surgeons concluded that the most plausible explanation was a trocar injury. The commentary discusses the risk of vascular and bowel injury during peritoneal access for laparoscopy and the importance of patient history and abdominal anatomy when considering approaches to abdominal entry.
WebM&M Cases
Commentary by Amy Nichols, EdD, RN, CNS, CHSE, ANEF |
A 61-year-old inpatient was on bedrest following postoperative complications. During the night shift, the hospital unit was short-staffed, and her external catheter system fell off. The patient rang her call button repeatedly to request nursing assistance and eventually hopped down the hallway on one leg to find assistance but was unsuccessful. By the time the nurse came to the bedside to change the patient’s urine-soaked bed pads and sheets, the patient was angry and agitated. The nurse responded defensively and began to talk to the patient in a condescending tone and another nurse complained to the family member that the patient was “behaving badly.” Ultimately, the patient decided to “leave against medical advice,” (AMA), citing she was extremely upset about how she was treated and spoken to. She and her family member were escorted downstairs to leave the hospital. No nurse or physician on duty was able to provide discharge education, instructions, or medications related to her DVT or urinary incontinence. The commentary discusses the risks of patients leaving AMA, summarizes effective communication strategies to mitigate the risk of patients leaving AMA and highlights strategies for prevention and de-escalation.
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.
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