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October 26, 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
Karanikas N, Khan SR, Baker PRA, et al. Safety Sci. 2022;156:105906.
Some patient safety interventions, such as checklists, are adapted or borrowed from other industries, such as aviation. This literature review focused on safety interventions developed in one context then implemented in another, such as healthcare. Healthcare was the largest sector represented, with 20 of the 73 included studies.
Roberts SE, Rosen CB, Keele LJ, et al. JAMA Surg. 2022;157:1097-1104.
Missed steps in the diagnostic process, such as timely referral for surgical consultation, can lead to missed or delayed diagnoses. This large, retrospective cohort study using Medicare data identified disparities between Black and White patients in receipt of consults for emergency surgery. Findings show that Black patients had lower odds of receiving a surgical consultation after being admitted from the emergency department; these disparities remained after adjusting for medical comorbidities, socioeconomic factors, and individual hospital-level effects.
Wong J, Lee S-Y, Sarkar U, et al. Am J Health Syst Pharm. 2022;79:2230-2243.
Medication errors in ambulatory care settings represent an ongoing patient safety challenge. This study characterizes ambulatory care adverse drug events reported to a large patient safety organization between May 2012 and October 2018. Anticoagulants, antibiotics, hypoglycemics, and opioids were the most commonly involved medication classes. Contributing factors included prescribing errors, failure to review clinical contraindications or drug-drug interactions, and lack of patient education or communication.
Shanafelt TD, West CP, Dyrbye LN, et al. Mayo Clinic Proc. 2022;97:2248-2258.
The COVID-19 pandemic has increased attention on clinician burnout and well-being. This survey of 2,440 US physicians identified an increase in burnout and decrease in satisfaction with work-life integration during the COVID-19 pandemic. Compared with earlier surveys (in 2011, 2014, 2017 and 2020), respondents reported higher mean emotional exhaustion scores, depersonalization scores, and burnout symptoms.
Alagoz E, Saucke M, Arroyo N, et al. J Patient Saf. 2022;18:711-716.
Patients transferring between hospitals have poorer outcomes than directly admitted patients, even when adjusting for other risk factors. In this study, transfer center nurses (TCN) described communication challenges that may influence patient outcomes. Themes included referring clinicians providing incomplete information, competing clinical demands, or fear of the transfer request being denied.
Michelson KA, McGarghan FLE, Patterson EE, et al. BMJ Qual Saf. 2022;Epub Sep 30.
Adverse events in pediatric emergency departments (ED) are rare, but largely preventable. This study examined characteristics and risk factors of patients with delayed diagnosis (i.e., presented to the ED within one week of a previous visit) and patients without delayed diagnosis of one of 7 serious medical conditions. Patients who were Hispanic or non-Hispanic Black, had public or other insurance, or non-English speaking were associated with delayed diagnosis.
Sacarny A, Safran E, Steffel M, et al. JAMA Health Forum. 2022;3:e223378.
Concurrent prescribing of opioids and benzodiazepines can put patients at increased risk of overdose. This randomized study found that pharmacist email alerts to clinicians caring for patients recently co-prescribed opioids and benzodiazepines did not reduce concurrent prescribing of these medications.
Paydar-Darian N, Stack AM, Volpe D, et al. Pediatrics. 2022;150:e2021054307.
Errors during the discharge process can lead to return visits and adverse health outcomes. This article describes the implementation of a new standardized discharge process (including a new checklist, provider huddle, and scripted caregiver education) at one children’s hospital. Over a 19-month period, implementation of the revised discharge process led to the elimination of preventable, discharge-related serious safety events and did not result in increased length-of-stay or return visits.
Wu G, Podlinski L, Wang C, et al. Jt Comm J Qual Patient Saf. 2022;48:665-673.
Simulation training is used to improve technical and nontechnical skills among healthcare teams. This study evaluated the impact of a one-hour interdisciplinary in situ simulation training on code response, teamwork, communication and comfort during intraoperative resuscitations. After simulation training, researchers noted improvements in technical skills of individuals and teams (e.g., CPR-related technical skills).
Pappa D, Koutelekos I, Evangelou E, et al. Healthcare (Basel). 2022;10:1803.
The physical and psychological well-being of healthcare providers can also improve patient safety. A survey of 364 nurses found that somatic symptoms (e.g., headache, exhaustion, fatigue) had a positive correlation with nursing errors, but other symptoms of burnout – such as anxiety or depression – did not. Resilience was associated with all aspects of general health and can be a helpful coping mechanism to prevent harm.
Wong J, Lee S-Y, Sarkar U, et al. Am J Health Syst Pharm. 2022;79:2230-2243.
Medication errors in ambulatory care settings represent an ongoing patient safety challenge. This study characterizes ambulatory care adverse drug events reported to a large patient safety organization between May 2012 and October 2018. Anticoagulants, antibiotics, hypoglycemics, and opioids were the most commonly involved medication classes. Contributing factors included prescribing errors, failure to review clinical contraindications or drug-drug interactions, and lack of patient education or communication.
Roberts SE, Rosen CB, Keele LJ, et al. JAMA Surg. 2022;157:1097-1104.
Missed steps in the diagnostic process, such as timely referral for surgical consultation, can lead to missed or delayed diagnoses. This large, retrospective cohort study using Medicare data identified disparities between Black and White patients in receipt of consults for emergency surgery. Findings show that Black patients had lower odds of receiving a surgical consultation after being admitted from the emergency department; these disparities remained after adjusting for medical comorbidities, socioeconomic factors, and individual hospital-level effects.
Kanter MH, Ghobadi A, Lurvey LD, et al. Diagnosis (Berl). 2022;9:430-436.
Diagnostic errors are an emerging area of patient safety research; as such, innovative methods to identify and prevent diagnostic errors are being developed. This commentary describes the development, implementation, and sustainment of a novel method of investigation. The e-Autopsy/e-Biopsy method includes dedicated patient safety staff and volunteer clinical specialists to review events and identify trends. The process is illustrated with three diagnoses: ectopic pregnancy, abdominal aortic aneurysms, and advanced colon cancer.
Lagu T, Haywood C, Reimold KE, et al. Health Aff (Millwood). 2022;41:1387-1395.
People with disabilities face barriers to safe, equitable care such as inaccessible equipment and facilities or provider bias. In this study, primary care and specialist physicians described challenges with caring for patients with disabilities. Many expressed explicit biases such as reluctance to care for people with disabilities, invest in accessible equipment, or obtain continuing education to provide appropriate care.
Hacker CE, Debono D, Travaglia J, et al. J Health Organ Manag. 2022;36:981-986.
Disinfection and cleaning of the hospital environment can promote a reduction in healthcare-associated infections. This commentary discussed the important, yet largely invisible, role of the hospital cleaning workforce. The authors also describe additional benefits provided by cleaners, such as reducing patient isolation and alerting clinical staff to patient changes.
Kanter MH, Ghobadi A, Lurvey LD, et al. Diagnosis (Berl). 2022;9:430-436.
Diagnostic errors are an emerging area of patient safety research; as such, innovative methods to identify and prevent diagnostic errors are being developed. This commentary describes the development, implementation, and sustainment of a novel method of investigation. The e-Autopsy/e-Biopsy method includes dedicated patient safety staff and volunteer clinical specialists to review events and identify trends. The process is illustrated with three diagnoses: ectopic pregnancy, abdominal aortic aneurysms, and advanced colon cancer.
Charles MA, Yackel EE, Mills PD, et al. J Patient Saf. 2022;18:686-691.
The first surge of the COVID-19 pandemic forced healthcare organizations to respond to patient safety issues in real-time. The Veterans Health Administration’s National Center for Patient Safety established two working groups to rapidly monitor quality and safety issues and make timely recommendations to staff. The formation, activities, and primary themes of safety issues are described.
Karanikas N, Khan SR, Baker PRA, et al. Safety Sci. 2022;156:105906.
Some patient safety interventions, such as checklists, are adapted or borrowed from other industries, such as aviation. This literature review focused on safety interventions developed in one context then implemented in another, such as healthcare. Healthcare was the largest sector represented, with 20 of the 73 included studies.
Roulson J, Benbow EW, Hasleton PS. Histopathology. 2005;47:551-559.
Autopsies are considered the gold standard in determining cause of death and identifying diagnostic errors that may have played a role in the death. Studies comparing antemortem and postmortem diagnosis published between 1967 and 2002 were included in this review. Rates of diagnostic discrepancies that could have impacted survival ranged from 10% to nearly 21%. Despite these discrepancies, autopsy rates continue to decline, missing opportunities to improve diagnostic education.
Ellis LA, Pomare C, Churruca K, et al. BMJ Open. 2022;12:e065320.
A strong safety culture encourages error reporting and supports a blame-free environment, and is frequently measured to develop appropriate interventions. This review identified nearly 900 studies that assessed hospital safety culture with response rates from 4% to 100%. The authors identify several factors that influence response rate: remote distribution (i.e., electronic or sent via mail), timing (e.g., beginning/end of resident rotations, COVID-19), and length of survey.
No results.
Washington DC: United States Government Accountability Office and National Academy of Medicine; September 2022. Report no. GAO-22-104629.
Machine learning is a subset of artificial intelligence that has potential to improve diagnosis. This report examines the value of existing machine learning diagnostic technologies and discusses concerns and policy impacts of their use over time. The authors suggest evaluation, data access and collaboration as strategies to enhance policy supporting technology development and safety.
Special or Theme Issue
Dixon-Woods M, Martin G, eds. Cambridge, UK: Cambridge University Press; 2022-2023.
Improvement activities are complex initiatives that require synergistic actions by organizations to be sustained. This evolving series provides background, evidence, and discussion on interdisciplinary strategies known to affect quality and safety such as implementation science, collaboration, positive deviance, and culture change.
Organizational Policy/Guidelines
Cooper J, Thomas BJ, Rebello E, et al for the APSF Criminalization of Error Task Force. APSF Newsletter. October 2022; 37(3):80-81
Criminalizing human error can deter the transparency necessary to learn from incidents and improve health care. This position statement articulates the importance of avoiding the criminal prosecution to mistakes to instead focus on system failures to prevent conditions that permit errors to harm patients.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute care edition. October 6, 2022;27(20):1-5.
Patient resuscitation is a complex, distinct, team activity that can be prone to error. Pharmacists involved in codes reported concerns including errors with high-alert medications and communication gaps. Improvement recommendations focused on preparation for, actions during and post code phrases which included standardizing the practice of including pharmacists in codes, simulation, and regular debriefing.
Tools/Toolkit
Rockville, MD: Agency for Healthcare Research and Quality; October 2022.
Inappropriate antibiotic prescribing is associated with increased risk potential. This toolkit assists in simplifying the antibiotic decision-making process. It is organized around a four-point decision aide and contains resources on using a stewardship program, communicating about prescribing and applying best practices for common infectious diseases.
Newspaper/Magazine Article
Lu D. The Guardian. October 18, 2022.
Disrespect for women around the world is known to occur in health care that contributes to diagnostic delay and lack of trust in the system. This news article describes challenges met by 5 women patients seeking diagnosis and treatment for long COVID.
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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