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April 5, 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
Bånnsgård M, Nouri A, Finizia C, et al. J Patient Saf. 2023;19(2):137-142.
Hospitalized patients are encouraged to take an active role in their safety. This study investigated two methods of informing patients of safety information, either by video, structured oral presentation, or both. Both methods were rated as good or very good. Of patients who viewed both, there was a slight, though not statistically significant, preference for the oral presentation.
Dresser S, Teel C, Peltzer J. Int J Nurs Stud. 2023;139:104436.
Understanding how nurses use their clinical judgment in activating early warning systems or rapid response teams is important in improving response to deteriorating patients. Interviews with 20 nurses revealed an overarching sense of responsibility to their patients, eight subthemes including experience, making sense of the data, and a culture of teamwork.
Idilbi N, Dokhi M, Malka-Zeevi H, et al. J Nurs Care Qual. 2023;38(3):264-271.
If reported, near misses – also called “good catches” – present opportunities for healthcare organizations to learn about potential errors, identify system improvements, and improve safety culture. This mixed-methods study including 199 nurses, who worked in COVID-19 units, found that intent to report near misses was high (78%) but follow-through on reporting was low (20%). Qualitative analyses highlight the role that personnel/physical/mental overload, poor departmental organization, and fear of punitive measures play in underreporting near-miss events.
Tai TWC, Mattie A, Miller SM, et al. J Healthc Risk Manag. 2023;42(3-4):21-29.
Healthcare-associated infections (HAIs) continue to be a preventable safety problem. This study explored the correlation between hospitals’ Leapfrog Hospital Safety Grade and Magnet designation on measures of patient safety, including healthcare-acquired infections (HAIs). The researchers found that Leapfrog safety scores were higher for Magnet-designated versus non-Magnet-designated hospitals – particularly for structural measures – but Magnet-designated hospitals did not have lower HAI rates.
Bånnsgård M, Nouri A, Finizia C, et al. J Patient Saf. 2023;19(2):137-142.
Hospitalized patients are encouraged to take an active role in their safety. This study investigated two methods of informing patients of safety information, either by video, structured oral presentation, or both. Both methods were rated as good or very good. Of patients who viewed both, there was a slight, though not statistically significant, preference for the oral presentation.
Friedson AI, Humphreys A, LeCraw F, et al. JAMA Netw Open. 2023;6(3):e232302.
Disclosure of adverse events to patients and families is an important component of safety culture. AHRQ's Communication and Optimal Resolution (CANDOR) program provides tools to guide the disclosure process as well as peer support for healthcare providers (HCP) involved in the adverse event. This study aimed to identify associations with CANDOR implementation and HCP job satisfaction. Results indicate implementation of CANDOR increased some measures of HCP job satisfaction and trust in leadership, a novel finding not previously reported.
Nasri B-N, Mitchell JD, Jackson C, et al. Surg Endosc. 2023;37(3):2316-2325.
Distractions in the operating room can contribute to errors. Based on survey responses from 160 healthcare workers, this study examined perceived distractions in the operating room. All participants ranked auditory distractions as the most distracting and visual distractions as the least distracting, but the top five distractors fell into the equipment and environmental categories – (excessive heat/cold, team member unavailability, poor ergonomics, equipment unavailability, and competitive demand for equipment). Phone calls/pagers/beepers were also cited as a common distractor.
Dresser S, Teel C, Peltzer J. Int J Nurs Stud. 2023;139:104436.
Understanding how nurses use their clinical judgment in activating early warning systems or rapid response teams is important in improving response to deteriorating patients. Interviews with 20 nurses revealed an overarching sense of responsibility to their patients, eight subthemes including experience, making sense of the data, and a culture of teamwork.
Evans ME, Simbartl LA, Kralovic SM, et al. Infect Control Hosp Epidemiol. 2023;44(3):420-426.
Healthcare-associated infections (HAIs) are among the most common complications of hospital or long-term care stays. HAI data reported to the Veterans Affairs centralized database was analyzed to determine rates of several HAIs, both before and during the pandemic, to assess changes. Rates were variable in acute care and no changes were seen in long-term care.
Bloo G, Calsbeek H, Westert GP, et al. J Patient Saf Risk Manag. 2023;28(1):31-46.
Racial and ethnic minoritized patients frequently have poorer postoperative outcomes. The hospital in this study found the opposite and sought the perspectives of minority and non-minority patients to explore potential contributing factors. Both groups of patients described positive communication with nurses and physicians, trust in the team, and family support. Only one unique factor came up for the ethnic minority patients: having someone, an interpreter, accompany them to the operating room made them feel safe.
Idilbi N, Dokhi M, Malka-Zeevi H, et al. J Nurs Care Qual. 2023;38(3):264-271.
If reported, near misses – also called “good catches” – present opportunities for healthcare organizations to learn about potential errors, identify system improvements, and improve safety culture. This mixed-methods study including 199 nurses, who worked in COVID-19 units, found that intent to report near misses was high (78%) but follow-through on reporting was low (20%). Qualitative analyses highlight the role that personnel/physical/mental overload, poor departmental organization, and fear of punitive measures play in underreporting near-miss events.
Martin G, Stanford S, Dixon-Woods M. BMJ. 2023;380:513.
The Francis report served as a call to action for improvement, following its recording of elements contributing to systemic failure within the British National Health Service (NHS). This commentary considers the overarching problems that still exist at the NHS and that listening, learning, and leadership involvement are core elements for driving and realizing lasting change throughout the system.
McIntosh MS, Garvan C, Kalynych CJ, et al. Jt Comm J Qual Patient Saf. 2023;49(4):207-212.
Physician burnout is widespread, can affect physician wellness, and threaten patient safety. This article describes the development of the Center for Healthy Minds and Practice (CHaMP) program at the University of Florida College of Medicine-Jacksonville, which aims to improve crisis response, build peer support, and remove barriers to accessing mental health care for medical students, clinicians, staff, and other healthcare workers.
Black GB, Lyratzopoulos G, Vincent CA, et al. BMJ. 2023;380:e071225.
Primary care often initiates a diagnostic process that is vulnerable to miscommunication, uncertainty, and delay. This commentary examines how cancer diagnosis delay in primary care occurs. The authors suggest a systems approach targeting interconnected process elements including enhanced use of information technology to help with monitoring and care coordination to realize and sustain improvement.
Gray KD, Subramaniam HL, Huang ES. JAMA Pediatr. 2023;177(5):459-460.
Previous research has identified racial and ethnic discrepancies in pulse oximetry measurement which can lead to delays in diagnosis or treatment. This editorial discusses racial and ethnic biases in clinical algorithms and devices and two emerging approaches – photoacoustic imaging and polarized light oximetry – that have potential to address the racial and ethnic biases in pulse oximetry.
Feinstein JA, Orth LE. J Pediatr. 2023;254:4-10.
Children with medical complexity (CMC) frequently take multiple medications, often from multiple prescribers. This commentary describes the particular vulnerabilities CMC face throughout the medication use cycle, along with ways for the prescriber and system to mitigate the risks of polypharmacy.
Wiig S, Macrae C, Frich J, et al. Front Public Health. 2023;11:1087268.
Patient safety incident investigations are important tools for identifying failures and facilitators of patient harm. This article provides an overview of the regulatory bodies in Norway that are involved in investigating adverse events and how the language used during these investigative activities can support or impede the process.
Zwaan L, Smith KM, Giardina TD, et al. Patient Educ Couns. 2023;110:107650.
Improving diagnosis and diagnostic error-related harm is a major focus within patient safety. Building on previous research, patients and patient advocates participated in a systematic prioritization exercise and prioritized ten diagnostic error reduction research priorities. Prioritized questions focused on improving care integration/coordination, communication between clinicians and patients/caregivers, improving patient reporting systems, and improved understanding of implicit bias, and underlying factors increasing risk for diagnostic errors among vulnerable patient groups. The authors note that these priorities differed more than those identified previously by diagnostic safety experts and stakeholders.
Abraham J, Duffy C, Kandasamy M, et al. Int J Med Inform. 2023;174:105038.
Multiple handoffs occur during the perioperative period, each presenting an opportunity for miscommunication and patient harm. This review uses the Systems Engineering Initiative for Patient Safety (SEIPS) framework to describe the barriers and enablers for improving staff communication pre-, intra-, and post-operative handoffs. Structured hand-offs, checklists, protocols, and interprofessional teamwork were cited as enablers for improved communication.
Feather C, Appelbaum N, Darzi A, et al. BMJ Qual Saf. 2023;32(6):357–368.
Requiring a prescriber to include an indication for a medication can reduce the risk of wrong-patient orders and improve antimicrobial and opioid stewardship. This review identified 21 studies describing interventions to encourage prescribers to include indications for medications. In addition to patient safety benefits, several risks and drawbacks were uncovered, such as potential loss of patient privacy or alert fatigue.
No results.
Farnborough, UK: Healthcare Safety Investigation Branch; March 2023.
Patient suicide is a sentinel event. This report examines a suicide incident that identified problems with risk assessment and identification, family engagement, and medication management in the context of mental health provision when supporting patients in psychological distress.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute care edition. March 23, 2023;28(6):1-4.
Medication mistakes are recognized contributors to patient harm. This article discusses medication errors that continue to occur despite established practices that, if applied, can mitigate error occurrence. Recommended areas of focus include reducing emphasis on the “Five Rights” to address system problems, enhancing medication list accuracy, and improving neuromuscular blocking agent storage.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Commentary by Michael Leonardo Amashta, MD, and David K. Barnes, MD, FACEP |
This case involves a procedural sedation error in a 3-year-old patient who presented to the Emergency Department with a left posterior hip dislocation. The commentary summarizes the indications and risks of procedural sedation in non-surgical settings and highlights the value of implementing system-wide safety protocols and practices to prevent medication administration errors during high-risk procedures.
WebM&M Cases
Charleen Singh, PhD, MSN/ED, FNP-BC, CWOCN, RN and Brent Luu, PharmD, BCACP |
This case represents a known but generally preventable complication of calcium chloride infusion, eventually necessitating surgical amputation of the patient’s left fourth (ring) finger. The commentary discusses the importance of correctly identifying IV fluids as irritants or vesicants, risks associated with the use of vesicants such as calcium chloride, and the role of early recognition of infiltration and extravasation and symptom management to minimize tissue damage and accelerate healing.
WebM&M Cases
Spotlight Case
Barbara Resnick, PhD, CRNP, and Marie Boltz, PhD, CRNP |
This Spotlight Case highlights two cases of falls in older patients in nursing homes. The commentary discusses how risk factors for falls should be considered in care planning and approaches to fall prevention in long-term care settings.
This Month’s Perspectives
Annual Perspective
Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD |
Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.
Interview
Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.
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