Email Updates
May 10, 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
Allen G, Setzer J, Jones R, et al. Jt Comm J Qual Patient Saf. 2023;49:247-254.
Reconciling medication lists at transitions of care is a widely recognized safety strategy; however, other parts of the electronic health record (EHR) - allergies and problem lists - also need reconciliation. This article describes an academic medical system's quality improvement project to increase rates of complete reconciliation of problems, medications, and allergies in the EHR. Twenty-six cycles of Plan-Do-Study-Act increased completion rates from 20% to 80%.
Arad D, Rosenfeld A, Magnezi R. Patient Saf Surg. 2023;17:6.
Surgical never events are rare but devastating for patients. Using machine learning, this study identified 24 contributing factors to two types of surgical never events - wrong site surgery and retained items. Communication, the number and type of staff present, and the type and length of surgery were identified contributing factors.
Mahajan P, Grubenhoff JA, Cranford J, et al. BMJ Open Qual. 2023;12:e002062.
Missed diagnostic opportunities often involve multiple process breakdowns and can lead to serious avoidable patient harm. Based on a web-based survey of 1,594 emergency medicine physicians, missed diagnostic opportunities most frequently occur in children who present to the emergency department with undifferentiated symptoms (e.g., abdominal pain, fever, vomiting) and often involve issues related to the patient/parent-provider interaction, such as misinterpreting patient history or inadequate physical exam.
Passini L, Le Bouedec S, Dassieu G, et al. BMJ Qual Saf. 2023;32:589-599.
Medical errors in the neonatal intensive care unit (NICU) are common and can result in significant patient harm. This prospective observational study conducted at 10 NICUs in France found that approximately 41% of the 1,822 errors (among 1,019 patients) were disclosed to the patient’s parents. Providers cited parental absence (i.e., the error occurred overnight) and perceived lack of serious consequences for the infant as the most frequent reason for non-disclosure.
Arad D, Rosenfeld A, Magnezi R. Patient Saf Surg. 2023;17:6.
Surgical never events are rare but devastating for patients. Using machine learning, this study identified 24 contributing factors to two types of surgical never events - wrong site surgery and retained items. Communication, the number and type of staff present, and the type and length of surgery were identified contributing factors.
Mortsiefer A, Löscher S, Pashutina Y, et al. JAMA Netw Open. 2023;6:e234723.
Polypharmacy among older adults can cause adverse health outcomes as well as adversely impact social outcomes, medication management, and healthcare utilization. The COFRAIL cluster randomized trial explored whether family conferences can promote deprescribing and reduce adverse outcomes related to polypharmacy in community-dwelling frail older adults. After 12 months of follow-up, the researchers did not find any significant difference in hospitalizations among patients randomized to family conferences or usual care. The number of potentially inappropriate prescriptions decreased among patients randomized to family conferences at 6-month follow-up, but this reduction was not sustained at the 12-month follow-up.
de Arriba Fernández A, Sánchez Medina R, Dorta Hung ME, et al. J Patient Saf. 2023;19:249-250.
As more patients with COVID-19 were admitted to hospitals during the pandemic, concerns about healthcare-acquired COVID-19 and potential associated adverse events increased. In this retrospective study, 126 patients with hospital-acquired COVID-19 were moved to isolation or quarantine. Twenty-nine patients experienced one or more adverse events due to isolation or quarantine, including delayed transfer to other specialties and delayed diagnostic tests. Nosocomial COVID-19 infection was confirmed as cause of death in one patient, and a possible cause in 11 others.
Hessels AJ, Guo J, Johnson CT, et al. Am J Infect Control. 2023;51:482-489.
Standard precautions, including hand hygiene and sharps safety, keep patients and staff safe, but adherence is suboptimal. An earlier systematic review shows an association between standard precaution compliance and overall safety climate. This study aimed to determine if adherence to standard precautions and safety climate were associated with healthcare associated infection (HAI) rates. Adherence rates were low (64%) and associated with HAI and healthcare worker needlesticks.
Allen G, Setzer J, Jones R, et al. Jt Comm J Qual Patient Saf. 2023;49:247-254.
Reconciling medication lists at transitions of care is a widely recognized safety strategy; however, other parts of the electronic health record (EHR) - allergies and problem lists - also need reconciliation. This article describes an academic medical system's quality improvement project to increase rates of complete reconciliation of problems, medications, and allergies in the EHR. Twenty-six cycles of Plan-Do-Study-Act increased completion rates from 20% to 80%.
Baffoe JO, Moczygemba LR, Brown CM. J Am Pharm Assoc (2003). 2023;63:518-528.
Minoritized and vulnerable people often experience delays in care due to systemic biases. This survey study examined the association between perceived discrimination at community pharmacies and foregoing or delaying picking up medications. Participants reported discrimination based on race, age, sexual orientation, ethnicity, income, and prescription insurance; those participants were more likely to delay picking up their medications. There was no association with discrimination and foregoing medications.
Kirwan G, O’Leary A, Walsh C, et al. Eur J Hosp Pharm. 2023;30:86-91.
Patients are particularly vulnerable to medication errors during transitions of care, such as hospital discharge. Based on clinical judgement from four experts assessing 81 cases involving medication errors at discharge, the authors estimated that between 61-85% would result in additional healthcare utilization (e.g., additional prescriptions, primary care or ED visits, hospital or ICU admissions) and additional costs.
Edwards SE, Class QA, Ford CE, et al. Am J Obstet Gynecol MFM. 2023;5:100927.
Racial bias negatively impacts maternal safety across all stages of pregnancy. This study used two clinical scenarios to assess obstetricians' likelihood to recommend cesarean section during labor at three decision points. All participants received the same scenarios with the only difference being the patient's race (i.e., Black or white). No significant racial biases were detected overall, but one subgroup (younger providers and those with less experience) opted for cesarean delivery more frequently for Black patients than white patients at one decision point.
Mahajan P, Grubenhoff JA, Cranford J, et al. BMJ Open Qual. 2023;12:e002062.
Missed diagnostic opportunities often involve multiple process breakdowns and can lead to serious avoidable patient harm. Based on a web-based survey of 1,594 emergency medicine physicians, missed diagnostic opportunities most frequently occur in children who present to the emergency department with undifferentiated symptoms (e.g., abdominal pain, fever, vomiting) and often involve issues related to the patient/parent-provider interaction, such as misinterpreting patient history or inadequate physical exam.
Carpenter C, Jotte R, Griffey RT, et al. Mo Med. 2023;120:114-120.
AHRQ's 2022 report Diagnostic Errors in the Emergency Department: A Systematic Review, which reported an estimated 7.4 million patients receive a misdiagnosis in the emergency department every year, garnered public, practitioner, and researcher attention. In this peer-reviewed commentary, the authors critique several components of the report. They also support AHRQ's recommended next steps, and further call for additional public and private funding opportunities to continue improving diagnostic accuracy in the emergency department.
Salmon PM, Hulme A, Walker GH, et al. Ergonomics. 2023;66:644-657.
Systems thinking concepts are used by healthcare organizations to encourage learning from failures and identifying solutions to complex patient safety problems. This article outlines a refined and validated set of systems thinking tenets and discusses how they can be used to proactively identify threats to patient safety.
Brown C, Brown M. Br J Nurs. 2023;32:326-332.
Incorrect patient registration, application of the wrong label, and blood draw from the wrong patient can all cause blood transfusion errors. This systematic review identified six studies related to nursing and blood transfusion safety. Errors fell into two broad categories - human and environmental factors, and education. Initial and continuing education for all members of the team, including registration staff, should be considered to improve and maintain transfusion safety.
van der Horst SFB, van Rein N, van Mens TE, et al. Thromb Res. 2023;231:135-140.
Although direct-acting oral anti-coagulants (DOACs) are considered safer than warfarin, DOAC dosing is complex and can lead to medication errors. This narrative review discusses the clinical consequences of potentially inappropriate inpatient prescribing of DOACs and how pharmacists and anticoagulant stewardship programs can optimize inpatient DOAC treatment.
Wawersik DM, Boutin ER, Gore T, et al. J Healthc Leadersh. 2023;15:59-70.
Psychological safety promotes speaking up and error reporting in the workplace, and many system and individual characteristics interact to promote or hinder reporting behavior. This review highlights individual characteristics that encourage error reporting, (confidence and positive perception of self, the organization, and leadership) or create barriers (self-preservation associated with fear and negative perceptions of self, the organization, and leadership).
No results.
Newspaper/Magazine Article
Mullins L, Menard F. WBUR. April 27, 2023.
Incomplete information and building design problems can reduce access to care and contribute to harm. This story outlines how the state of Massachusetts responded to the accidental death of a patient unable to get help due to poor signage and incomplete directional information while experiencing an asthma attack.
Covid Crisis Group. New York: Public Affairs; 2023. ISBN: 9781541703803.
The transfer of failure experiences to generate learning and improve service is a complicated responsibility. This book examines breakdowns in the US response to the COVID-19 epidemic to understand causes of the problems, in order to better prepare health care, government, and public health systems for future pandemics. It also discusses what successes were achieved and how to capitalize on those improvements.
Legislation/Regulation
118th Cong (2023-2024).
Nurse staffing and patient care outcomes are linked, yet variation exists in nursing coverage throughout the United States. This submitted bill aims to legislate a national minimum nurse-to-patient staffing ratio as a strategy to enhance safety and quality improvement.
Special or Theme Issue
ACS TQIP Mortality Reporting System Writing Group. J Trauma Acute Care Surg. 2023.
Anonymous case reporting provides opportunities to examine unexpected patient harm instances to pinpoint process changes and enhance learning. This case series shares analysis of adverse events submitted to a trauma center-focused reporting program as tools for improvement. The cases are freely available.
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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