Email Updates
May 17, 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
Detollenaere J, Van Ingelghem I, Van den Heede K, et al. Eur J Pediatr. 2023;182:2735-2757.
The hospital-at-home (HAH) model allows patients to receive hospital-level care in their homes. This systematic review identified 25 articles (18 interventions) comparing outcomes of pediatric HAH care to standard in-hospital care. Hospital at home was not associated with increased hospital readmissions or adverse events. However, the quality of the studies was low to very low, and additional high-quality research is required.
Machen S. BMJ Open Qual. 2023;12:e002020.
Learning from patient safety incidents can help health care organizations improve processes and care delivery. This article provides a template for organizations to review patient safety incidents and classify them into themes from a human factors and systems thinking perspective. The process involves clearly characterizing the safety incidents, describing the involved safety systems, identifying and classifying contributing factors, completion of narrative analysis to identify commonalities and differences in the way contributing factors affect the incidents, and identification of safety recommendations.
Rainer T, Lim JK, He Y, et al. Hosp Pediatr. 2023;13:461-470.
Structural racism and implicit biases can affect clinical judgement and impede the delivery of effective mental health care. Based on a case of an adolescent Black girl navigating through the pediatric behavioral health system, this article discusses how structural racism and health disparities in behavioral health care contributed to misdiagnosis and poor care. The authors outline several actions at the structural, institutional, and interpersonal levels to address racism’s impact on pediatric mental and behavioral healthcare.
Yackel EE, Knowles RS, Jones CM, et al. J Patient Saf. 2023;19:340-345.
The COVID-19 pandemic dramatically changed healthcare delivery and exacerbated threats to patient safety. Using Veterans Health Administration (VHA) National Center for Patient Safety data, this retrospective study characterized patient safety events related to COVID-19 occurring between March 2020 and February 2021. Delays in care and exposure to COVID-19 were the most common events and confusion over procedures, missed care, and failure to identify COVID-positive patients before exposures were the most common contributing factors.
Donzé JD, John G, Genné D, et al. JAMA Internal Med. 2023;183:658-668.
Adverse events and unplanned, preventable readmissions occur in approximately 20% of patients following discharge from the hospital. This randomized clinical trial compares standard care with a multi-modal discharge intervention targeting patients at highest risk of unplanned readmission. Despite the intensity of the intervention, there was no statistical difference between that intensity and the standard of care in unplanned readmission, time to readmission, or death.
Garzón González G, Alonso Safont T, Zamarrón Fraile E, et al. Int J Qual Health Care. 2023;35:mzad019.
Research into the nature, type, and contributing factors of adverse events (AE) in primary care is required to develop successful safety interventions. This study used medical record review to determine the prevalence, preventability, severity, type, and contributory factors of AE in primary care in Madrid, Spain. The prevalence of AEs was 5%, with the majority determined to be preventable. Most resulted in mild harm, and most contributory factors were patient-related (e.g., self-administered medications).
Kepner S, Jones RM. Patient Saf. 2023;5:6-19.
Pennsylvania requires all acute care facilities to report incidents and serious events to the Pennsylvania Patient Safety Reporting System (PA-PSRS). This report compiles reports submitted for Q1 and Q2 2022 and compares results to previous years. There was a decrease in the total number of reports submitted, but serious and high harm events increased. The most frequently reported event continues to be Error Related to Procedure/Treatment/Test followed by Complication of Procedure/Treatment/Test, Medication Error, and Fall. In November 2023, an update was published reflecting the addition of Q3 and Q4 2022 data.
Seeburger EF, Gonzales R, South EC, et al. JAMA Netw Open. 2023;6:e239057.
Verbal or physical violence towards healthcare workers can result in harm of both staff and patients. Based on semi-structured interviews with 25 registered nurses working in the emergency department (ED) at one large academic health system, the authors explored nursing perspectives on how EHR-based behavioral flags – used to identify incidents of workplace violence – can promote clinician safety. Participants identified benefits of the flags as well as concerns (e.g., introduction of bias, potential damage to the patient-clinician relationship), highlighted necessary system improvements, and how related challenges in the ED (e.g., unmet mental health needs of patients, COVID-19-related burnout) can contribute to workplace violence.
Correia T, Martins MM, Barroso F, et al. Nurs Rep. 2023;13:634-643.
Family involvement in care can have mixed results for patient safety. Interviews with nurses show seven ways families can hinder safety and ten ways they improve safety. The risk of infection was the greatest safety threat and being a unique source of information helped increase patient safety. Interestingly, "greater workload for nurses" was identified as a facilitator of patient safety, potentially, as it lowered the stress experienced by the nurse and increased family satisfaction and positive involvement.
Comolli L, Korda A, Zamaro E, et al. BMJ Open. 2023;13:e064057.
Patients presenting to the emergency department (ED) with a chief complaint of dizziness require prompt assessment to rule in or out a serious diagnosis such as stroke. A retrospective chart review was performed on more than 1,500 adult patients presenting to the ED with dizziness to estimate vestibular syndrome classifications (i.e., acute, episodic, chronic) and rates of misdiagnosis. Approximately 20% of patients were diagnosed with acute vestibular syndrome (e.g., stroke) and 10% had an unclear vestibular syndrome at time of ED discharge. Of those with follow-up exams, nearly one-third received a different diagnosis, but only 3.2% received a different vestibular classification.
Powell M. J Health Org Manag. 2023;37(1):67-83.
Individual, team, and organizational willingness to identify and address safety problems is an important indicator of safety culture. The authors of this article apply ten perspectives on organizational silence to understand the organizational failures contributing to dangerous opioid prescribing practices at Gosport Hospital.
Abebe E, Bao A, Kokkinias P, et al. Explor Res Clin Soc Pharm. 2023;9:100216.
The patient safety movement recognizes that most errors occur at the system level, not the individual level, and therefore uses a systems approach toward improving patient safety. A similar systems approach can be used by pharmacy programs to enhance the education of pharmacy students. This article describes the sociotechnical framework of healthcare (structures, processes, outcomes) and parallels with pharmacy programs.
Organizational Policy/Guidelines
Moran JM, Bazan JG, Dawes SL, et al. Pract Radiat Oncol. 2023;13:203-216.
Safety risks are present in oncology radiation therapy. This recommendation builds on existing intensity modulated radiation therapy (IMRT) standards to highlight the importance of interdisciplinary engagement, training, and technology implementation to ensure high quality, safe IMRT is delivered to patients.
Rainer T, Lim JK, He Y, et al. Hosp Pediatr. 2023;13:461-470.
Structural racism and implicit biases can affect clinical judgement and impede the delivery of effective mental health care. Based on a case of an adolescent Black girl navigating through the pediatric behavioral health system, this article discusses how structural racism and health disparities in behavioral health care contributed to misdiagnosis and poor care. The authors outline several actions at the structural, institutional, and interpersonal levels to address racism’s impact on pediatric mental and behavioral healthcare.
Royce CS, Morgan HK, Baecher-Lind L, et al. Am J Obstet Gynecol. 2023;228:369-381.
Racism and implicit biases can threaten the safety of care. The authors in this article outline how implicit bias can affect health professional trainees and impact patient care in obstetrics and gynecology, and outlines strategies to address implicit bias through bias awareness and management curricula, ensuring a supportive learning environment, and faculty development.
Machen S. BMJ Open Qual. 2023;12:e002020.
Learning from patient safety incidents can help health care organizations improve processes and care delivery. This article provides a template for organizations to review patient safety incidents and classify them into themes from a human factors and systems thinking perspective. The process involves clearly characterizing the safety incidents, describing the involved safety systems, identifying and classifying contributing factors, completion of narrative analysis to identify commonalities and differences in the way contributing factors affect the incidents, and identification of safety recommendations.
Lai B, Horn J, Wilkinson J, et al. Fam Pract Manag. 2023;30(2):13-17.
Morbidity and mortality (M&M) conferences are an established mechanism used to facilitate discussion of errors to generate learning. This peer-reviewed article discusses how one organization implemented an M&M program. The authors share steps taken to support success which include case selection, nonjudgmental culture, and subject matter expert involvement.
Awad S, Amon K, Baillie A, et al. Int J Med Inform. 2023;172:105017.
Computerized provider order entry (CPOE), clinical decision support (CDS), and electronic medication management systems (EMMS) have increased efficiency and reduced prescribing errors, but poor design may introduce new safety hazards. Human factors and safety analysis methods can be used to increase the safety of new technologies, ideally before problems arise. This review identifies human factors and safety analysis methods applied to EMMS. Most methods focused on usability or design, and only one used a safety-oriented approach. Increased inclusion of human factors specialists could increase the use of safety-oriented methods of EMMS design.
Detollenaere J, Van Ingelghem I, Van den Heede K, et al. Eur J Pediatr. 2023;182:2735-2757.
The hospital-at-home (HAH) model allows patients to receive hospital-level care in their homes. This systematic review identified 25 articles (18 interventions) comparing outcomes of pediatric HAH care to standard in-hospital care. Hospital at home was not associated with increased hospital readmissions or adverse events. However, the quality of the studies was low to very low, and additional high-quality research is required.
Vikan M, Haugen AS, Bjørnnes AK, et al. BMC Health Serv Res. 2023;23:300.
A culture of safety is essential to the delivery of high-quality, safe healthcare. This scoping review including 34 studies found that patient safety culture scores were generally associated with reduced adverse event rates, but the authors note a paucity of research from primary care settings and low- and middle-income countries as well as a need for longitudinal studies using standardized measures to better examine this relationship.
No results.
Newspaper/Magazine Article
Freedman DH. Newsweek Magazine. May 12, 2023.
The unintended consequences of reductions in access to prescription opioids can result in poor addiction care and ineffective pain management. This article discusses precursors to the system failure affecting these patients and treatment options that work given access and supply constraints.
Newspaper/Magazine Article
Weintraub K. USA Today. May 3, 2023.
The semi-annual Leapfrog Hospital Safety Grades are recognized across the industry as a tool for highlighting successes and tracking gaps in safety to focus improvement efforts. This article shares one organization’s work to improve core safety activities related to medication safety, falls, infections, and hand hygiene.
Farnborough, UK: Healthcare Safety Investigation Branch; April 2023.
Misattribution of child maltreatment injuries can be a serious misdiagnosis affecting families and patients. This report analyzes ten safety incident reports from across the British National Health Service to explore how non-accidental injury was missed. Themes identified as contributing to the problems include lack of information sharing, inconsistent guidance, and emergency department care demands.
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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