Email Updates
February 8, 2023 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
Farzandipour M, Nabovati E, Sharif R. J Telemed Telecare. 2023;Epub Jan 23.
Remote triage allows patients to receive guidance about whether to seek care and, if required, what level of care. This review of remote triage focuses exclusively on tele-triage studies conducted during the COVID-19 pandemic. The studies reported on five broad outcome categories (access to care, triage rates, patient safety, post-triage clinical outcomes, and patient satisfaction) with highly positive outcomes.
Fridman M, Korst LM, Reynen DJ, et al. Jt Comm J Qual Patient Saf. 2023;49:129-137.
Severe maternal morbidity (SMM) is an international public health concern and the focus of hospital quality improvement activities. This article describes the development of a performance SMM (pSMM) that can be used to quantify potentially preventable, hospital-acquired SMM. The Centers for Disease Control and Prevention (CDC) SMM measure was adapted and results are stratified by hospital type.
Namiranian, MD, PhD K. J Opioid Manag. 2023;19:69-76.
Prescription opioids are commonly used to manage surgical and non-surgical pain but misuse of opioids is a serious patient safety concern. In this retrospective cohort study of Veterans Health Administration patients, researchers found that opioid misuse among previously opioid-naïve patients increases significantly after 11 months of chronic use, regardless of whether the opioid was prescribed for surgical or non-surgical pain.
Reinhart RM, Safari-Ferra P, Badh R, et al. Pediatrics. 2023;151:e2022056452.
Trigger tools are widely used for detecting potential adverse events among adult and pediatric inpatients. This article describes the development of a pediatric triggers program that can identify potential adverse events in near real-time to facilitate appropriate preventative measures. The tool includes criteria from the IHI Global Trigger Tool as well as novel triggers (such as pain reassessment time, hospital readmissions, and suspected sepsis). The trigger team created a process for linking triggers to the organizational incident reporting system based on specific criteria (to reduce false-positive reports). The trigger team is continuously developing and refining triggers based on stakeholder input.
Harada Y, Otaka Y, Katsukura S, et al. BMJ Qual Saf. 2024;33:386-394.
Context, such as patient, clinician, location, or specialty, can affect the type and frequency of diagnostic errors. In this novel study, the diagnostic errors of a cohort of clinicians who practice in multiple locations (i.e., outpatient and emergency department) with different referral types (i.e., scheduled visit, urgent visit, emergency visit) was evaluated. Using the Revised Safer Dx instrument, researchers identified significantly more diagnostic errors in patients with scheduled visits compared to urgent or emergent referrals. The results indicate, that among clinicians in the same specialty, it may be contextual factors (i.e., referral type) that affect diagnostic errors rather than specialty.
Vacheron C-H, Acker A, Autran M, et al. J Patient Saf. 2023;19:e13-e17.
Wrong-site, wrong-procedure, and wrong-patient errors (WSPEs) are serious adverse events. This retrospective analysis of medical liability claims data examined the incidence of WSPEs in France between 2007 and 2017. During this ten-year period, WSPEs accounted for 0.4% of all claims. Procedures on the wrong organ were most common (44%), followed by wrong side (39%), wrong person (13%) and wrong procedure (4%). The researchers found that the average number of WSPEs decreased after implementation of a surgical checklist.
Kim S, Kitzmiller R, Baernholdt MB, et al. Workplace Health Saf. 2022;71:78-88.
Physical and verbal violence against healthcare workers has been identified as a sentinel event by the Joint Commission. In this secondary analysis of survey data on workplace violence (WPV), researchers explored which attributes of patient safety culture may predict healthcare workers’ experiences of WPV and burnout. Better teamwork and staffing were among the attributes associated with lower risk of WPV.
Amdani S, Conway J, Kleinmahon J, et al. JACC Heart Fail. 2023;11:19-26.
Research has shown clinicians frequently have implicit biases against patients of color, women, and transgender patients. This study used Implicit Association Tests (IAT) to evaluate implicit bias in pediatric heart transplant clinicians. Results showed these clinicians had a bias, or preference for, individuals who were White, from a higher socio-economic group, and had more education. These results are similar to other adult and pediatric clinicians.
Namiranian, MD, PhD K. J Opioid Manag. 2023;19:69-76.
Prescription opioids are commonly used to manage surgical and non-surgical pain but misuse of opioids is a serious patient safety concern. In this retrospective cohort study of Veterans Health Administration patients, researchers found that opioid misuse among previously opioid-naïve patients increases significantly after 11 months of chronic use, regardless of whether the opioid was prescribed for surgical or non-surgical pain.
Fridman M, Korst LM, Reynen DJ, et al. Jt Comm J Qual Patient Saf. 2023;49:129-137.
Severe maternal morbidity (SMM) is an international public health concern and the focus of hospital quality improvement activities. This article describes the development of a performance SMM (pSMM) that can be used to quantify potentially preventable, hospital-acquired SMM. The Centers for Disease Control and Prevention (CDC) SMM measure was adapted and results are stratified by hospital type.
Klasen JM, Beck J, Randall CL, et al. Acad Pediatr. 2023;23:489-496.
As part of clinical learning, residents and trainees are sometimes allowed to make supervised mistakes when patient safety is not at risk. In this study, pediatric hospitalists describe potential benefits and risks of allowing failure, the process of allowing or interrupting failure, and how they decide to allow failure to happen. Consistent with previous research, patient, trainee, team, and institutional factors were identified. Additionally, caregiver/parent factors were noted.
Hwang J, Kelz RR. BMJ Qual Saf. 2023;32:61-64.
Patient safety improvements must consider the complexities of care delivery to achieve lasting change. This commentary discusses recent evidence examining the effect of duty hour limit adjustments. The authors highlight challenges regarding research design on this medical education policy change and how it affects learner and patient experience. They suggest caution in applying the study conclusions.
Edlow JA, Pronovost PJ. JAMA. 2023;329:631-632.
Medical errors should be examined in the context of system failure to generate lasting opportunities for learning and improvement. This commentary discusses the AHRQ 2022 report entitled Diagnostic Errors in the Emergency Department: a Systematic Review and suggests a focus on care delivery processes over individuals, definitions, error rate review, and system design as noteworthy approaches to error reduction.
Hoffmann DE, Fillingim RB, Veasley C. J Law Med Ethics. 2022;50:519-541.
Women’s pain has been underestimated compared to men’s pain, and treatments differ based on gender. This commentary revisits the findings from the 2001 article The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain. The authors state progress has been made in the past 20 years, but disparities still exist. Additional research is needed, particularly into chronic pain conditions that are more common in women.
Boskeljon‐Horst L, Sillem S, Dekker SWA. J Contingencies Crisis Manag. 2022;31:372-391.
High-reliability organizations frequently assess the strength of their safety culture. In this article, researchers compare the results of a safety culture assessment (SCA) of a helicopter squadron and investigation of an accident that occurred shortly after survey administration. Results of the SCA showed the safety culture was mature, but the investigation revealed otherwise, indicating the SCA had little predictive value.
St Clair B, Jorgensen M, Nguyen A, et al. Gerontol Geriatr Med. 2022;8:23337214221144192.
Older adults in long-term care settings can be vulnerable to patient safety incidents. This scoping review of 46 articles identified several gaps in the research on adverse events in long-term care and nursing home settings, including the absence of resident perspectives regarding safety and the role of interpersonal and environmental factors on the incidence of adverse events.
Gómez-Pérez V, Escrivá Peiró D, Sancho-Cantus D, et al. Healthcare (Basel). 2023;11:263.
The redeployment of clinicians at the beginning of the COVID-19 public health emergency necessitated rapid training of staff, particularly those assigned to the intensive care unit (ICU). This review identified effective in-situ simulations that could be used in ICUs to restore and sustain patient safety following the COVID-19 pandemic. The in-situ simulations were able to detect latent safety threats and improve patient safety culture, interprofessional communication, and system organization.
Farzandipour M, Nabovati E, Sharif R. J Telemed Telecare. 2023;Epub Jan 23.
Remote triage allows patients to receive guidance about whether to seek care and, if required, what level of care. This review of remote triage focuses exclusively on tele-triage studies conducted during the COVID-19 pandemic. The studies reported on five broad outcome categories (access to care, triage rates, patient safety, post-triage clinical outcomes, and patient satisfaction) with highly positive outcomes.
Surian D, Wang Y, Coiera E, et al. J Am Med Inform Assoc. 2022;30:382-392.
Health information technology (HIT), such as electronic health records (EHRs) or computerized provider order entry (CPOE) systems, are important approaches to improving safety. This scoping review of 45 articles found that machine learning and statistical modeling are the most commonly used automated, HIT-based methods for early detection of safety threats. Machine learning was often used to detect errors occurring in laboratory test results, prescriptions, and patient records. Statistical modeling was used to detect issues with clinical decision support systems.
Meeting/Conference Proceedings
Patient safety is a dynamic discipline that adjusts regularly to address clinical, organizational and policy changes, and disruptions. This webinar series presents sessions exploring insights on a variety of strategies and experiences to enhance care.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute care edition. January 26, 2023:28(2):1-4.
Look-alike and sound-alike drug names are a perpetual cause for confusion that decreases medication safety. This article discusses the results of a national survey on the importance of mixed case drug names, which found that 94% of the 298 respondents reported using mixed case drug names in their organization and that the majority of participants felt that mixed case lettering prevents drug selection events. The survey also identified new drug names for inclusion on the 2023 list revision.
Award Announcement
Chicago, IL: American College of Graduate Medical Education.
Lewis Blackman was a young man who lost his life to medical error when the severity of his condition after elective surgery was unrecognized by clinicians caring for him. This award will acknowledge residents and fellows engaged in developing educational programs on patient safety. Nominations for the 2025 award cycle are due March 27, 2024.
Newspaper/Magazine Article
R3 Report. December 20, 2022;38:1-8.
Health care inequities persist despite increasing awareness they negatively affect quality, safety, and patient centeredness. This article shares the Joint Commission strategy for embedding equity improvement into the National Patient Safety Goal initiative to increase focus on equity as a safety priority across all care environments.
Hare R, Tyler ER, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2023. AHRQ Publication No. 23-0018.
The AHRQ Surveys on Patient Safety Culture™(SOPS®) Nursing Home Survey assesses safety culture and resident safety in nursing homes. This report summarizes survey data from 3,224 staff working in 62 nursing homes. Respondents reported positive perceptions about both resident safety overall and feedback and communication regarding safety incidents. Areas for improvement included sufficient staffing to handle the workload and maintain resident safety.
This Month’s WebM&Ms
WebM&M Cases
Dahlia Zuidema, PharmD, Berit Bagley, MSN, and Charity L Tan MSN |
This WebM&M highlights two cases of hospital-acquired diabetic ketoacidosis (DKA) in patients with type 1 diabetes. The commentary discusses the role of the inpatient glycemic team to assist with diabetes management, the importance of medication reconciliation in the emergency department (ED) for high-risk patients on insulin, and strategies to empower patients and caregivers to speak up about medication safety.
WebM&M Cases
Elizabeth Partridge, MD, MPH, Daniel Dodson, MD, MS, Mary Reilly, MHA, BSN, RN, CIC and Stuart H. Cohen, MD |
A 5-day old male infant was admitted to the pediatric intensive care unit (PICU) and underwent surgery to correct a congenital heart defect. The patient’s postoperative course was complicated Staphylococcus aureus bacteremia and other problems, requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) and subsequent cardiac procedures. During these subsequent procedures, he was found to have florid mediastinitis including multiple pockets of purulent material; the chest tissue culture collected during surgery demonstrated Aspergillus fumigatus. The patient returned to PICU with an open chest to optimize antibacterial and antifungal therapies for a hospital-acquired invasive fungal infection in an immunocompetent infant. The commentary discusses environmental factors that contribute to postoperative infections and approaches to mitigating environmental infectious disease hazards in perioperative spaces.
WebM&M Cases
Spotlight Case
Claire E. Graves, MD and Maggie A. Kuhn, MD, MAS |
These cases describe the rare but dangerous complication of hematoma following neck surgery. The first case involves a patient with a history of spinal stenosis who was admitted for elective cervical discectomy and cervical disc arthroplasty who went into cardiopulmonary arrest three days post-discharge and could not be intubated due to excessive airway swelling and could not be resuscitated. Autopsy revealed a large hematoma at the operative site, causing compression of the upper airway, which was the suspected cause of respiratory and cardiac arrest. In the second case, the patient underwent an uncomplicated elective thyroid lobectomy but developed increased neck pain and swelling the next day. A large hematoma was identified, and the patient was taken emergently to the operating room for evacuation. The commentary discusses risk factors for postoperative cervical hematomas, the importance of prompt identification and evaluation of cervical hematomas in the early postoperative period, and approaches for managing postoperative cervical hematomas.
This Month’s Perspectives
Interview
Connor Wesley, RN, BSN, is a registered nurse in Tacoma, WA. In addition to his role as the Assistant Nurse Manager of the Emergency Department at MultiCare Allenmore Hospital, Connor lectures locally and nationally on providing healthcare to members of the lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) community. We interviewed Connor to discuss patient safety and the LGBTQ+ community.
Perspective
<p>Connor Wesley, RN, BSN, Cindy Manaoat Van, MHSA, Sarah E. Mossburg, RN, PhD</p> |
This piece discusses patient safety concerns among members of the LGBTQ+ community which may inhibit access to needed healthcare and potential ways to provide patient-centered care and mitigate the risk of adverse events.
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!
