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February 15, 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
Bose S, Groat D, Dinglas VD, et al. Crit Care Med. 2023;51:212-221.
Medication discrepancies at discharge are a known contributor to hospital readmission, but nonmedication needs may also contribute. In this study, 200 survivors of acute respiratory failure were followed up 7-28 days post discharge to assess unmet nonmedication discharge needs (i.e., durable medical equipment, home health services, follow-up medical appointments). Nearly all patients had at least one unmet need, but this was not associated with hospital readmission or mortality within 90 days.
Jeffers NK, Berger BO, Marea CX, et al. Soc Sci Med. 2023;317:115622.
Structural racism contributes to high rates of severe maternal morbidity (SMM) experienced by Black patients. This study investigated specific measures of structural racism (incarceration inequality and racialized economic segregation) on Black SMM. In this sample of births from 2008-2011, racialized economic segregation was associated with SMM for black patients; however, incarceration inequality was not.
Maierhofer CN, Ranapurwala SI, DiPrete BL, et al. Drug Alcohol Depend. 2023;242:109727.
A national focus on reducing opioid misuse and abuse has resulted in changes to opioid prescribing policies and practice. This retrospective longitudinal study explored changes in prescribing rates, supply and dose of opioid prescriptions after changes in opioid prescribing policies in North Carolina. Researchers found that that prescribing patterns for acute and postsurgical pain patients (but not chronic pain patients) decreased after a state medical board initiative to reduce high-dose and high-volume. Further, new legislation to limit initial opioid prescriptions for acute and postsurgical pain led to a decrease in prescribing for cancer patients with chronic pain, but did not lead to reductions among patients with acute, postsurgical, or non-cancer chronic pain.
Vanhaecht K, Seys D, Russotto S, et al. Int J Environ Res Public Health. 2022;19:16869.
‘Second victim’ is controversial term used to describe health care professionals who experience continuing psychological harm after involvement in a medical error or adverse event. In this study, an expert panel reviewed existing definitions of ‘second victim’ in the literature and proposed a new consensus-based definition.
Bose S, Groat D, Dinglas VD, et al. Crit Care Med. 2023;51:212-221.
Medication discrepancies at discharge are a known contributor to hospital readmission, but nonmedication needs may also contribute. In this study, 200 survivors of acute respiratory failure were followed up 7-28 days post discharge to assess unmet nonmedication discharge needs (i.e., durable medical equipment, home health services, follow-up medical appointments). Nearly all patients had at least one unmet need, but this was not associated with hospital readmission or mortality within 90 days.
Engle RL, Gillespie C, Clark VA, et al. J Gerontol Nurs. 2023;49:13-17.
Nurses’ willingness to speak up about resident safety concerns varies based on anticipated leadership response and support. Clinical and non-clinical staff at six Department of Veterans Affairs (VA) nursing homes with diverse safety climate ratings (high, medium, low) were interviewed to understand the association between resident safety and safety climate. Staff at high safety climate facilities described open communication and leadership responsiveness as contributors to a strong safety climate and willingness to speak up.
Sempere L, Bernabeu P, Cameo J, et al. Inflamm Bowel Dis. 2023;29:1886-1894.
Women often experience misdiagnosis and diagnostic delays due to process failures and implicit bias. This multicenter cohort study including 190 patients found that women were more likely to experience delays in diagnosis and misdiagnosis of inflammatory bowel disease, as compared to men. Researchers found that these inequities in misdiagnosis occurred across all healthcare settings (emergency department, primary care, gastroenterology, and hospital admission).
Maierhofer CN, Ranapurwala SI, DiPrete BL, et al. Drug Alcohol Depend. 2023;242:109727.
A national focus on reducing opioid misuse and abuse has resulted in changes to opioid prescribing policies and practice. This retrospective longitudinal study explored changes in prescribing rates, supply and dose of opioid prescriptions after changes in opioid prescribing policies in North Carolina. Researchers found that that prescribing patterns for acute and postsurgical pain patients (but not chronic pain patients) decreased after a state medical board initiative to reduce high-dose and high-volume. Further, new legislation to limit initial opioid prescriptions for acute and postsurgical pain led to a decrease in prescribing for cancer patients with chronic pain, but did not lead to reductions among patients with acute, postsurgical, or non-cancer chronic pain.
Jeffers NK, Berger BO, Marea CX, et al. Soc Sci Med. 2023;317:115622.
Structural racism contributes to high rates of severe maternal morbidity (SMM) experienced by Black patients. This study investigated specific measures of structural racism (incarceration inequality and racialized economic segregation) on Black SMM. In this sample of births from 2008-2011, racialized economic segregation was associated with SMM for black patients; however, incarceration inequality was not.
Morris RL, Giles SJ, Campbell S. Health Expect. 2023;Jan 16.
Patient and caregiver engagement is an important strategy for improving the quality and safety of care. This qualitative study with 18 patients and/or caregivers explored perspectives on engagement in primary care. While participants were supportive of engagement in their care and safety, some expressed concerns regarding additional workload for patients. Participants also provided feedback on a patient safety guide for primary care (PSG-PC) and identified areas to embed the PSG-PC into routine interactions with primary care, particularly for individuals caring for a family member with complex or chronic health conditions.
Bell SK, Dong ZJ, DesRoches CM, et al. J Am Med Inform Assoc. 2023;30:692-702.
Patients and families are encouraged to play an active role in patient safety by, for example, reporting inaccurate or incomplete electronic health record notes after visits. In this study, patients and families at two US healthcare sites (pediatric subspecialty and adult primary care) were invited to complete a survey (OurDX) before their visit to identify their visit priority, recent medical history/symptoms, and potential diagnostic concerns. In total, 7.5% of patients and families reported a potential diagnostic concern, mainly not feeling heard by their provider.
Wong CI, Vannatta K, Gilleland Marchak J, et al. Cancer. 2023;129:1064-1074.
Children with complex home care needs, such as children with cancer, are particularly vulnerable to medication errors. This longitudinal study used in-home observations and chart review to monitor 131 pediatric patients with leukemia or lymphoma for six months and found that 10% experienced adverse drug events due to medication errors in the home and 42% experienced a medication error with the potential for harm. Failures in communication was the most common contributing factor. Findings underscored a critical need for interventions to support safe medication use at home. Researchers concluded that improvements addressing communication with and among caregivers should be co-developed with families and based on human-factors engineering.
Schnock KO, Garber A, Fraser H, et al. Jt Comm J Qual Patient Saf. 2023;49:89-97.
Reducing diagnostic errors is a primary patient safety concern. This qualitative study based on interviews with 17 providers and two focus group with seven patient advisors found broad agreement that diagnostic errors pose a significant threat to patient safety, as participants had difficulty defining and describing, and correctly identifying. the frequency of diagnostic errors in acute care settings. Participants cited issues such as communication failures, diagnostic uncertainty, and cognitive load as the primary factors contributing to diagnostic errors.
Vargas V, Blakeslee WW, Banas CA, et al. PLoS ONE. 2023;18:e0279903.
Medication reconciliation can help identify medication discrepancies during transitions of care. This study examined the impact of a complete medication history database to support pharmacist-led medication reconciliation and identification of medication discrepancies during the admission process for patients at one psychiatric hospital. A retrospective analysis identified 82 medication errors; 90% of these errors – primarily dosage discrepancies and omissions – could have led to patient harm if not corrected through pharmacist intervention.
Vanhaecht K, Seys D, Russotto S, et al. Int J Environ Res Public Health. 2022;19:16869.
‘Second victim’ is controversial term used to describe health care professionals who experience continuing psychological harm after involvement in a medical error or adverse event. In this study, an expert panel reviewed existing definitions of ‘second victim’ in the literature and proposed a new consensus-based definition.
Commentary
Lyndon A, Davis D-A, Sharma AE, et al. BMJ Qual Saf. 2023;32:369-372.
Patient perspectives can provide unique insights into care quality. This commentary examines how ascertaining whether patients ‘feel safe’ results in their ‘being safe’ is an ineffective goal in patient safety. The authors argue that patient experiences degrading humanity be considered never events and suggest feelings as important considerations for patient engagement and health care improvement.
Borycki EM, Kushniruk AW. Healthc Manage Forum. 2023;51:212-221.
Health technology has improved many aspects of care, but can also introduce new safety concerns that require active monitoring and improvement. This commentary describes how learning health systems can improve the safety of new technologies, such as hiring health informaticists and collaborations with health authorities and vendors.
Michel C, Talley C. J Health Life Sci Law. 2022;17(1):71
High-profile medication errors like that of Tennessee nurse RaDonda Vaught provide opportunities for learning and debate. In this commentary, the authors discuss the legal aspects of the incident, share reasons for the criminal conviction rendered in this case, and present the decision’s potential impact on subsequent disciplinary actions.
Kelly FE, Frerk C, Bailey CR, et al. Anaesthesia. 2023;78:479-490.
Human factors science focuses on designing systems that make it easy for workers to do the right thing and difficult to do the wrong thing. This narrative review focuses on human factors science in anesthesia. Research is described as it relates to the hierarchy of controls model: design, barriers, mitigations, education, and training.
Balestracci B, La Regina M, Di Sessa D, et al. Intern Emerg Med. 2023;18:275-296.
The COVID-19 pandemic extended face-masking requirements from healthcare providers to the general public and patients. This review summarizes the challenges mask wearing poses to the general public. Challenges include discomfort, communication issues, especially for people with hearing loss, and skin irritation. Despite these issues, the authors state the benefits outweigh the risks of masks and appropriate education may improve mask use.
Li CJ, Nash DB. Am J Med Qual. 2022;37:545-556.
The Accreditation Council for Graduate Medical Education (ACGME) encourages graduate and undergraduate medical education programs to include the Quality Improvement and Patient Safety (QIPS) curriculum. This review summarizes the status of QIPS programs in the United States. Program length varied widely, from two simulation-based sessions to a two-year QIPS fellowship. Only a quarter of programs used a standardized, validated QIPS evaluation tool, and resident satisfaction and information retention was mixed.
No results.
Newspaper/Magazine Article
Renault M. STAT. February 6, 2023.
Emergent care situations are vulnerable to a range of factors that reduce care safety and access. This article examines safety culture, implicit biases, and system issues that impacted access to needed emergency care for a patient involved in a police action.
Rockville, MD: Agency for Healthcare Research and Quality; January 2023. AHRQ Pub. No.22(23)-0065-1.
Research has shown that involving patients, their families and caregivers, in the planning, delivery, and evaluation of their healthcare can improve safety and quality. This collection of AHRQ-funded work includes summaries of 53 projects since 2000 that contributed to environments in which patients, families, and healthcare professionals work together to improve the quality and safety of care. Efforts highlighted include those involving patients and families in activities designed to report and ultimately prevent medical errors and near misses.
Newspaper/Magazine Article
Wicklund E. HealthLeaders. January 19, 2023.
Technologies both advance and challenge care safety. This article summarizes an annual analysis spotlighting health technology that may contribute to patient harm. Issues with home-based tools and single-use devices were underscored as priorities for improvement by both care organizations and equipment manufacturers.
Newspaper/Magazine Article
Quick Safety. January 16 2023;(67):1-3.
Maternal safety is compromised by a range of social, cognitive, and clinical factors. This article discusses how poor maternal mental health can contribute to patient death. It recommends screening, a care safety plan, and the warm handoff as strategies to improve safety.
Special or Theme Issue
Tingle J. Br J Nurs. 2001-2024.
This series of commentaries discusses a wide range of policy, legal, and operational topics related to patient safety in the British health system, such as artificial intelligence, patient communication and harm compensation.
Feske-Kirby K, Whittington J, McGaffigan P. Boston, MA: Institute for Healthcare Improvement; 2022.
The potential of machine learning to improve care and safety is emerging as its application increases across health care. This report examines how machine learning can improve activities such as risk identification and prediction. It also discusses barriers to its use such as workload, expertise gaps, and system integration.
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.
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