March 22, 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
Taft T, Rudd EA, Thraen I, et al. J Am Med Inform Assoc. 2023;30(5):809-818.
Medication administration errors are major threats to patient safety. This qualitative study with 32 nurses from two US health system explored medication administration hazards and inefficiencies. Participants identified ten persistent safety hazards and inefficiencies, including issues with communication between safety monitoring systems and nurses, alert fatigue, and an overreliance on medication administration technology. These findings highlight the importance of developing medication administration technology in collaboration with frontline nurses who are tasked with medication administration.
Washington A, Randall J. J Racial Ethn Health Disparities. 2023;10(2):883-891.
Discrimination can contribute to health inequities and exacerbate disparities in cancer care. In this study, researchers used a survey tool and qualitative interviews to explore the experiences of perceived discrimination for Black women and how it impacts cervical cancer prevention. Study findings suggest that perceived high degrees of discrimination create mistrust between patients and providers and can impact health outcomes.
Zabin LM, Zaitoun RSA, Sweity EM, et al. BMC Nurs. 2023;22(1):39.
Fostering a culture of safety is an essential component of improving patient safety and health care quality. This systematic review of seven articles identified a negative relationship between job-related stress among nurses and patient safety culture. Studies also reported that factors such as fatigue, workload, burnout, and workplace violence contribute to job-related stress and resulted in decreased patient safety culture.
Taft T, Rudd EA, Thraen I, et al. J Am Med Inform Assoc. 2023;30(5):809-818.
Medication administration errors are major threats to patient safety. This qualitative study with 32 nurses from two US health system explored medication administration hazards and inefficiencies. Participants identified ten persistent safety hazards and inefficiencies, including issues with communication between safety monitoring systems and nurses, alert fatigue, and an overreliance on medication administration technology. These findings highlight the importance of developing medication administration technology in collaboration with frontline nurses who are tasked with medication administration.
Washington A, Randall J. J Racial Ethn Health Disparities. 2023;10(2):883-891.
Discrimination can contribute to health inequities and exacerbate disparities in cancer care. In this study, researchers used a survey tool and qualitative interviews to explore the experiences of perceived discrimination for Black women and how it impacts cervical cancer prevention. Study findings suggest that perceived high degrees of discrimination create mistrust between patients and providers and can impact health outcomes.
Gjøvikli K, Valeberg BT. J Patient Saf. 2023;19(2):93-98.
Closed-loop communication prevents confusion and ensures the healthcare team is operating under a shared mental model. In order to investigate closed-loop communication in real-life care (as opposed to simulations), researchers observed 60 interprofessional teams, including 120 anesthesia personnel. The number of callouts, check-backs, and confirmations were analyzed, revealing only 45% of callouts resulted in closed-loop communication.
Strandbygaard J, Dose N, Moeller KE, et al. BMJ Open Qual. 2022;11(4):e001819.
Operating room (OR) “black boxes”– which combine continuous monitoring of intraoperative data with video and audio recording of operative procedures – are increasingly used to improve clinical and team performance. This study surveyed OR professionals in Denmark and Canada about safety attitudes and privacy concerns regarding OR black box use. Participants were primarily concerned with safety climate and teamwork in the OR and use of OR black boxes can support learning and improvements in these areas. The North American cohort expressed more concerns about data safety.
Brooks K, Landeg O, Kovats S, et al. BMJ Open. 2023;13(3):e068298.
National and organizational emergency response plans lay out policies and procedures to prepare for and respond to unexpected natural disasters and other public health emergencies. This study examines clinician and non-clinician perspectives on safety during the 2019 record-breaking heatwave in the United Kingdom. Clinicians reported not being aware of national heatwave preparedness and response plans, and several challenges were mentioned, including insufficient cooling equipment.
Wang X, Zhao Y. J Healthc Eng. 2023;2023:8934444.
Empowering patients to ensure safe care is one component of patient engagement. This analysis of 456 patients found that self-efficacy increased patient engagement in their care and led to increased patient safety.
Winqvist I, Näppä U, Rönning H, et al. Int J Qual Stud Health Well-being. 2023;18(1):2185964.
Improving care transitions is a patient safety priority. Based on interviews with 21 nurses in Sweden, this study explored nursing concerns regarding transitions of care from inpatient to home healthcare settings in rural areas. Participants cited concerns regarding care coordination, communication, and logistics.
Godby Vail S, Dierst-Davies R, Kogut D, et al. Jt Comm J Qual Patient Saf. 2023;49(2):79-88.
Burnout, characterized by emotional exhaustion that results in depersonalization and decreased accomplishment at work, is correlated with poor patient safety culture. Multiple initiatives to measure and reduce healthcare worker burnout have emerged recently. This Department of Defense study used the AHRQ Hospital Survey on Patient Safety Culture to determine the scope of burnout in military hospitals, explore the relationship between burnout and teamwork, and explore effects of teamwork on burnout.
Moraes SM, Ferrari TCA, Beleigoli A. Int J Qual Health Care. 2023;34(1):mzad005.
The IHI Global Trigger Tool (GTT) is used to detect adverse events (AE) in hospitalized patients, but studies have shown variability in the types and rates of errors detected. In this study, researchers aimed to determine the accuracy of the GTT through a diagnostic test study. The GTT showed satisfactory sensitivity, specificity, and global accuracy for AE detection, but performed better when minor harm AEs were excluded.
Salwei ME, Anders S, Slagle JM, et al. J Patient Saf. 2023;19(2):e38-e45.
Understanding deviations in care can identify opportunities to improve care delivery and patient safety. This study assessed the incidence and nature of patient- and clinician-reported deviations from optimal care (“non-routine events” or NRE) during ambulatory surgery. The most common type of clinician-reported NRE was process deficiencies, while failures in communication between clinicians and patients or family members was the most common type of patient-reported NRE. Understanding patient perspectives on care deviations can identify opportunities for process improvements and more patient-centered care.
No results.
Pisciotta W, Arina P, Hofmaenner D, et al. Anaesthesia. 2023;78(4):501-509.
A 2012 review estimated that diagnostic errors in the intensive care unit (ICU) may contribute to up to 8% of patient deaths. This narrative review identifies common causes of diagnostic error (e.g., cognitive bias) and suggests a diagnostic framework. Cognitive de-biasing strategies and increasing time spent with the patient are recommended as strategies for reducing diagnostic errors in this vulnerable patient population.
Kerray FM, Yule SJ, Tambyraja AL. J Surg Educ. 2023;80(5):619-623.
Error management training (EMT) encourages learners to make errors during training, and then engage in positive discussions about recognition of those errors. This commentary calls for increased use of EMT for surgical students and residents to promote error recovery.
Richmond JG, Burgess N. J Health Organ Manag. 2023;37(3):327-342.
Healthcare professionals who are involved in patient safety incidents can experience psychological distress. Using three case examples from surgery, urology, and maternity care, this study explored the emotional experience of healthcare professionals involved in patient safety incidents. The authors discuss the importance of providing support for recovery after involvement in a patient safety incident and protecting professionals from workplace pressures.
Zabin LM, Zaitoun RSA, Sweity EM, et al. BMC Nurs. 2023;22(1):39.
Fostering a culture of safety is an essential component of improving patient safety and health care quality. This systematic review of seven articles identified a negative relationship between job-related stress among nurses and patient safety culture. Studies also reported that factors such as fatigue, workload, burnout, and workplace violence contribute to job-related stress and resulted in decreased patient safety culture.
Haerdtlein A, Debold E, Rottenkolber M, et al. J Clin Med. 2023;12(4):1320.
Adverse drug events (ADE) can result in patient harm, hospital admissions, and, in severe cases, death. This systematic review and meta-analysis estimates the prevalence of preventable ADEs resulting in emergency department visits or hospitalization, and the types and prevalence of ADEs and implicated drugs. The drug groups with the highest reported prevalence rates were ‘nervous system’, ‘cardiovascular system’, and ‘blood and blood-forming organs’.
No results.
Grant Announcement
PAR-23-120. Bethesda, MD: National Institutes of Health; March 7, 2023
Approaching diagnosis as a team activity is seen as a key approach to diagnostic effectiveness. This notice highlights a funding opportunity to launch Diagnostic Centers of Excellence to improve diagnosis of undiagnosed and unknown disease and research to inform improvement. The application period is now closed.
Newspaper/Magazine Article
Sausser L. Kaiser Health News. March 13, 2023.
Lack of access to appropriate testing, procedures, and medications due to system barriers is a patient safety concern. This article highlights the contribution pre-authorization has on care delivery complexity that can result in patient harm.
Newspaper/Magazine Article
Schorsch K, Karp S. WBEZ Chicago. March 9, 2023.
Pediatric mental health is a patient safety concern. This news story outlines the challenges to available services to address this need, tactics to keep young patients from harming themselves or others, and system-level approaches to improvement.
Newspaper/Magazine Article
Tamayo-Sarver J. Fast Company. March 13, 2023.
Artificial intelligence (AI) harbors risks and biases that can misinform clinicians, researchers, and patients. This article discusses experience with an AI application in the emergency setting and the diagnostic mistakes it made. The author offers caution when proceeding with the use of AI as a diagnostic tool.
Rockville, MD: Agency for Healthcare Research and Quality; March 2024. AHRQ Pub. No. 23-0046.
The Network of Patient Safety Databases (NPSD) serves a central role in understanding the current state of care as tracked by patient safety measures. The 2024 Chartbook offers an overview of nonidentifiable, aggregated patient safety event, and near-miss information, voluntarily reported to data collection initiatives across the United States between 2000 and 2023. The Chartbook includes a summary of trends, disparities findings, and figures illustrating select patient safety measures.
This Month’s WebM&Ms
WebM&M Cases
Christian Bohringer, MD |
A 48-year-old woman was placed under general anesthesia with a laryngeal mask. The anesthesiologist was distracted briefly to sign for opioid drugs in a register, and during this time, the end-tidal carbon dioxide alarm sounded. Attempts to manually ventilate the patient were unsuccessful. The anesthesiologist asked for suxamethonium (succinylcholine) but the drug refrigerator was broken and the medication had to be retrieved from another room. The commentary discusses risk factors for laryngospasm, strategies to minimize distractions in the operating room and the importance of readily available neuromuscular blocking drugs and airway resuscitation equipment in operating rooms and other patient areas where laryngospasm is likely to occur.
WebM&M Cases
Spotlight Case
James A. Bourgeois, OD, MD, and Glen Xiong, MD |
An adult woman with a history of suicidal ideation was taking prescribed antidepressants, but later required admission to the hospital after overdosing on her prescribed medications. A consulting psychiatrist evaluated the patient but recommended sending her home on a benzodiazepine alone, under observation by her mother. The commentary discusses challenges in assessing suicide risk and establishing the underlying diagnosis after a suicide attempt, the importance of managing relationships between psychiatric consultants and other physicians, and the role of appropriate pharmacotherapy and follow-up after the patient has medically recovered from a suicide attempt.
WebM&M Cases
Lucy Shi, MD and Erik Noren, MD, MS |
A 71-year-old man presented to his physician with rectal bleeding and pain, which was attributed to radiation proctitis following therapy for adenocarcinoma of the prostate. He subsequently developed a potentially life-threatening complication of sepsis while awaiting follow up care for a spontaneous rectal perforation. The commentary addresses the importance of early identification and timely intervention in the event of treatment failure and the post-discharge follow-up programs to improve care coordination and communication during transitions of care.
This Month’s Perspectives
Interview
Christie Allen is the Senior Director of Quality Improvement at the American College of Obstetrics and Gynecology (ACOG). We spoke to her about her experience in maternal safety and improving perinatal mental healthcare, which is care for mental health conditions during pregnancy and the twelve months following delivery
Perspective
<p>Colton Hood, MD, MBI, Neal Sikka, MD, Cindy Manaoat Van, MHSA, Sarah E. Mossburg, RN, PhD</p> |
This piece discusses the evolution of remote patient monitoring, emergence into use with acute conditions, patient safety considerations, and the continued challenges of telehealth implementation.
