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June 7, 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
Jones BE, Sarvet AL, Ying J, et al. JAMA Netw Open. 2023;6:e2314185.
Pneumonia is one of the most common healthcare-acquired infections and can result in significantly longer lengths of stay and increased costs. In this retrospective study of more than six million hospitalized Veterans Health Administration patients, approximately 1 in 200 patients developed non-ventilator-associated hospital-acquired pneumonia (NV-HAP). Length of stay and mortality were significantly higher for patients with NV-HAP.
Sanghavi P, Chen Z. JAMA Netw Open. 2023;6:e2314822.
Underreporting patient safety events can hinder opportunities for improvement. Building on previous research, this study examined the association between nursing home characteristics and reporting patterns for two measures of nursing home care quality (falls with major injury and pressure ulcers). Findings suggest underreporting of both measures, and researchers identified an association between underreporting and the racial and ethnic composition of the nursing home facility.
Schneider P, Lorenz A, Menegay MC, et al. Am J Obstet Gynecol MFM. 2023;5:100912.
Reducing maternal morbidity and mortality continues to be a patient safety priority in the United States. The article describes the implementation of a quality improvement initiative in Ohio to improve outcomes for patients with a severe hypertensive event during pregnancy or postpartum. Among 29 participating hospitals between July 2020 and September 2021, the researchers identified sustained improvements in timely and appropriate treatment for severe hypertension, timely follow-up appointment after hospital discharge, and patient education about urgent maternal warning signs across both non-Hispanic Black and White pregnant or postpartum people.
Delpino R, Lees-Deutsch L, Solanki B. BMJ Open Qual. 2023;12:e002047.
Following the 2013 release of the Report of The Mid Staffordshire NHS Foundation Trust inquiry, National Health Service (NHS) Trusts have made substantial efforts to increase staffs’ willingness to speak up about patient safety concerns. One method is the creation of confidential resources who provide staff support: Freedom to Speak Up Guardians (FTSUG) and Confidential Contacts (CC). This study explored perspectives of FTSUG and CC on how they best support staff and how leaders can encourage speaking up behavior.
Hagström J, Blease CR, Kharko A, et al. Stud Health Technol Inform. 2023;302:242-246.
Patients are increasingly able to access their health record via electronic patient portals and many report finding errors in the record. This study asked adolescent (ages 15-19) patient portal users if they had identified errors or omissions in their record, and if so, did they report them to their provider. Approximately one-quarter of patients identified an error and 20% identified an omission. The majority of those patients did not report it to the clinic or healthcare provider.
Alqenae FA, Steinke DT, Carson-Stevens A, et al. Ther Adv Drug Saf. 2023;14:204209862311543.
Medication errors and adverse drug events (ADE) are unfortunately common at hospital discharge. This study used the National Reporting and Learning System (NRLS) in England and Wales to identify contributing causes to medication errors and ADE. Patients over 65 were the most common age group and, of incidents with a stated level of harm, most did not result in any harm. Overall, most incidents occurred at the prescribing stage, but varied by patient age group. Most contributory factors were organizational (e.g., continuity of care between provider types), followed by staff, patient, and equipment factors.
Fisher L, Hopcroft LEM, Rodgers S, et al. BMJ Medicine. 2023;2:e000392.
Pharmacists play a critical role in medication safety. This article evaluated the impact of a pharmacist-led information technology intervention (PINCER) among a retrospective cohort of 56.8 million National Health Service (NHS) patients across 6,367 general practices between September 2019 and September 2021. Findings indicate that potentially dangerous prescribing (i.e., prescribing medications to patients without associated blood test monitoring, co-prescribing medications with adverse indications, prescribing medications to patients with certain comorbidities) was largely unaffected by the COVID-19 pandemic.
Khan A, Karavite DJ, Muthu N, et al. J Patient Saf. 2023;19:251-257.
For incidents to be properly addressed, incident reports must be appropriately identified and categorized by safety managers. This study compared the categorization of incidents as involving health information technology (HIT) or not involving HIT by specialists trained in HIT and patient safety and safety managers trained in traditional methods of health safety. Safety managers only agreed with the HIT specialist classification 25% and 75% of the time on incidents involving or not involving HIT, respectively. Increased education for safety managers on the interaction of HIT and patient safety may result in better classification of HIT-related incidents.
Longo BA, Schmaltz SP, Barrett SC, et al. Jt Comm J Qual Patient Saf. 2023;49:313-319.
Delivering health care in the home presents unique patient safety challenges. In this study, researchers identified significant associations between Joint Commission accreditation and measures of patient experience and patient safety with home health.
Wimmer S, Toni I, Botzenhardt S, et al. Pharmacol Res Perspect. 2023;11:e01092.
Computerized physician order entry (CPOE) systems can prevent medication ordering and dispensing errors. This pre-post study compared medication safety outcomes for paper-based prescribing versus CPOE-based prescribing among pediatric patients at one German hospital. The researchers found that CPOE implementation resulted in fewer potentially harmful medication errors.
Jones BE, Sarvet AL, Ying J, et al. JAMA Netw Open. 2023;6:e2314185.
Pneumonia is one of the most common healthcare-acquired infections and can result in significantly longer lengths of stay and increased costs. In this retrospective study of more than six million hospitalized Veterans Health Administration patients, approximately 1 in 200 patients developed non-ventilator-associated hospital-acquired pneumonia (NV-HAP). Length of stay and mortality were significantly higher for patients with NV-HAP.
Caspi H, Perlman Y, Westreich S. Safety Sci. 2023;164:106147.
Near-misses or “good catches” are incidents that could have resulted in patient harm but did not due to it being caught at the last minute or through sheer luck. Reporting near-misses can help organizations learn and enact changes if necessary, but near-misses are not frequently reported. This study presents enablers and barriers to reporting near-misses.
Schneider P, Lorenz A, Menegay MC, et al. Am J Obstet Gynecol MFM. 2023;5:100912.
Reducing maternal morbidity and mortality continues to be a patient safety priority in the United States. The article describes the implementation of a quality improvement initiative in Ohio to improve outcomes for patients with a severe hypertensive event during pregnancy or postpartum. Among 29 participating hospitals between July 2020 and September 2021, the researchers identified sustained improvements in timely and appropriate treatment for severe hypertension, timely follow-up appointment after hospital discharge, and patient education about urgent maternal warning signs across both non-Hispanic Black and White pregnant or postpartum people.
Sanghavi P, Chen Z. JAMA Netw Open. 2023;6:e2314822.
Underreporting patient safety events can hinder opportunities for improvement. Building on previous research, this study examined the association between nursing home characteristics and reporting patterns for two measures of nursing home care quality (falls with major injury and pressure ulcers). Findings suggest underreporting of both measures, and researchers identified an association between underreporting and the racial and ethnic composition of the nursing home facility.
Bourne RS, Jeffries M, Phipps DL, et al. BMJ Open. 2023;13:e066757.
Patients transitioning from the intensive care unit (ICU) to the general ward are vulnerable to medication errors. This qualitative study included medical staff and clinical pharmacists from hospital wards and ICUs to identify factors that contribute to medication safety or adverse events at times of transition. Lack of communication between provider types (e.g., nurse and pharmacist) and time pressure considerations had negative effects on medication safety. Ward rounds and safety culture had positive effects.
Carter RG, Lake S. Pediatrics. 2023;151.
This commentary co-written by a medical student and a faculty member explores the presence and impact of implicit bias on the clinician team and patients. The piece introduces a four-step framework through which to examine the origins of bias, how its described, its care impact and how to reduce its effect.
Wilson E, Daniel M, Rao A, et al. Diagnosis (Berl). 2023;10:68-88.
Clinical decision-making is a complex process often involving interactions with multiple team members, processes, and systems. Using distributed cognition theory and qualitative synthesis, this scoping review including 37 articles identified seven themes addressing how distribution of tasks influences clinical decision-making in acute care settings The themes included information flow, task coordination, team communication, situational awareness, electronic health record (EHR) design, systems-level error, and distributed decision-making.
Zaitoun RA, Said NB, de Tantillo L. BMC Nurs. 2023;22:173.
Nurses play an important role in ensuring patient safety. This systematic review identified 16 studies examining the relationship between nursing competence and safety culture. The researchers identified several gaps in the evidence, including the need for rigorous research measuring the association between safety culture and nursing safety competencies and evaluating the effect of nursing safety competency on safety culture scores.
Larsson F, Strömbäck U, Rysst Gustafsson S, et al. Int J Qual Stud Health Well-being. 2023;18:2216018.
Patients expect to "feel safe" in healthcare settings. This concept analysis describes defining attributes (participation, control, presence) of patients in the perioperative environment. Through a series of cases that include all, some, or none of the safety attributes, the authors illustrate the concept of patients "feeling safe" in the perioperative environment.
No results.
Newspaper/Magazine Article
Jaklevic MC. CNN. May 30, 2023.
Patient safety has long drawn from aviation safety strategies to inform improvement. This article examines the potential for transparency and learning should a National Patient Safety Board be established in the United States. Like the National Transportation Safety Board concept, the proposed agency would collect data on facilities where errors occurred, which is discussed as a barrier to acceptance of the safety board approach in health care.
Newspaper/Magazine Article
Kopf M, Beck C. NBC News. May 26, 2023.
Lack of access to appropriate cancer medications can be particularly difficult for patients and clinicians. This news article discusses the current shortage of chemotherapy drugs, the psychological and physical harm potential in the situation and what should be done to improve medication supply.
Grossman D, Joffe C, Kaller S, et al. Advancing New Standards in Reproductive Health, University of California, San Francisco; 2023.
Overarching policy decisions have the potential to impact systems of care and harm patients. This document reports the preliminary findings of a study examining 50 cases submitted where clinicians modified care standards in response to abortion access limitations. The changes affected the timeliness, quality, safety, cost, and complexity of care delivered to pregnant patients.
This Month’s WebM&Ms
WebM&M Cases
Tai Huu Pham, MD and Surabhi Atreja, MD |
During an elective diagnostic cardiac catheterization, the cardiologist unintentionally perforated the patient’s left ventricular wall with the catheter. The cardiologist failed to recognize the perforation, failed to take corrective measures to address the problem, and continued with the cardiac catheterization, including coronary angiographic imaging. Soon after the end of the procedure, the patient complained of severe chest pain and echocardiographic images revealed bleeding around the heart caused by the catheter-related ventricular wall perforation. The patient underwent emergency exploratory surgery to fix the perforation within 40 minutes thereafter, but he did not survive. The commentary discusses the risks associated with diagnostic cardiac catheterization due to both patient- and operator-related factors and the importance of effective team communication and immediate recognition of iatrogenic injuries.
WebM&M Cases
Spotlight Case
Anna Curtin, MD and Nina Schloemerkemper, MD, FRCA |
A 25-year-old obese patient required an emergency cesarean delivery. As the obstetric team was in a hurry to deliver the baby, the team huddle was rushed. After the delivery, the anesthesia care provider discovered that the patient had received subcutaneous enoxaparin 40 mg four hours preoperatively, which was not mentioned by the obstetric team during the previous huddle. The patient developed a dense, persistent motor and sensory block of the lower limbs at 6 to 8 hours after delivery, which gradually wore off and the patient recovered without any permanent sensory or motor impairment. The commentary highlights the importance of preoperative huddles and pre-incision time out checklists to improve patient outcomes as well as the role of emergency cesarean simulation training for obstetric, anesthesia and nursing care teams.
WebM&M Cases
Spotlight Case
Elizabeth Gould, NP-C, CORLN, Kathleen M Carlsen, PA, Brooks T Kuhn, MD, MAS, and Jonathan Trask, RN |
A 56-year-old man was admitted to the hospital and required mechanical ventilation due to COVID-19-related pneumonia and acute respiratory failure. The care team performed a tracheostomy percutaneously at the bedside with some difficulty. The tracheostomy tube was secured, inspected via bronchoscopy, and properly sutured. During the next few days, the respiratory therapist noticed a leak that required additional inflation of the cuff to maintain an adequate seal. Before the care team could change the tracheostomy, the tracheal cuff burst, and the patient developed hypotension and required 100% inhaled oxygen via the ventilator. The commentary summarizes best practices regarding proper tracheostomy tube choice and sizing to prevent leaks around cuffs, the importance of staff education on airway cuff pressure monitoring, and the role of multidisciplinary tracheostomy teams to optimize tracheostomy care.
This Month’s Perspectives
Interview
Beverley H. Johnson, FAAN |
Beverley H. Johnson is the president and CEO of the Institute for Patient- and Family-Centered Care (IPFCC). We spoke to her about her experience in patient and family engagement and improving patient safety, including how to continue to partner with families during pandemics and through technology.
Perspective
Beverley H. Johnson, FAAN, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD |
This piece discusses how family presence and participation in healthcare at all levels can improve patient safety as well as how the COVID-19 pandemic affected partnership with patients and families, ultimately highlighting the critical importance of family presence and participation.
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