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June 14, 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
Chen H-W, Wu J-C, Kang Y-N, et al. Nurse Educ Today. 2023;126:105831.
Patient safety can be improved when all staff feel empowered to speak up about errors. In this systematic review, the authors identified 11 studies on the effectiveness of trainings to increase nurses' assertiveness to report medical errors. Interventions resulted in significant improvement in nurses' speaking up behavior, but not their attitude or confidence after training. Structured content, use of multiple teaching approaches, and adequate training time were critical to significant improvement.
Scholliers A, Cornelis S, Tosi M, et al. Br J Anaesth. 2023;130:622-635.
Clinicians often work long hours with irregular schedules, which can contribute to fatigue. This scoping review of 30 studies identified several patient safety risks associated with fatigue in anesthesia providers, including deterioration in non-technical skills, increased medication errors, poor attention and psychomotor decline.
Willis DN, Looper K, Malone RA, et al. Pediatr Qual Saf. 2023;8:e660.
Reducing healthcare-associated infections (HAIs) is a patient safety priority. This article describes the development of a quality improvement initiative to reduce central line-associated bloodstream infections (CLABSI) on one pediatric oncology ward. The initiative included four key interventions – huddles to improve identification of patients at risk for CLABSI, leadership safety rounds, partnership with the vascular access team, and hospital-acquired condition (HAC) rounding cards to prompt discussions on central line functionality. This multimodal approach led to a significant reduction in CLABSI rates between 2020 and 2021, and an increase in CLABSI-free days.
Grant Recipient
Rockville, MD: Agency for Healthcare Research and Quality; 2023.
The Agency for Healthcare Research and Quality (AHRQ) offers many practical tools and resources to help healthcare organizations, providers, and others make patient care safer These tools are based on research, and they can assist staff in hospitals, emergency departments, long-term care facilities, and ambulatory settings to prevent avoidable complications of care. The purpose of this challenge is to elicit new narratives of how AHRQ toolkits are being used. The winners of the competition are University of Missouri, University of Chicago Medicine and Chesapeake Regional Healthcare.
Pool N, Hebdon M, de Groot E, et al. Front in Public Health. 2023;11:1014773.
Clinical decision-making can be influenced by both individual and team factors. This article describes the de Groot Critically Reflective Diagnoses Protocol (DCRDP), which can be used to evaluate how group dynamics and interactions can influence collective clinical decision-making. Transcripts of recorded decision-making meetings can be coded based on six DCRPD criteria (challenging groupthink, critical opinion-sharing, research utilization, openness to mistakes, asking and giving feedback, and experimentation), which identify teams that are interactive, reflective, higher functioning, and more equitable.
Willis DN, Looper K, Malone RA, et al. Pediatr Qual Saf. 2023;8:e660.
Reducing healthcare-associated infections (HAIs) is a patient safety priority. This article describes the development of a quality improvement initiative to reduce central line-associated bloodstream infections (CLABSI) on one pediatric oncology ward. The initiative included four key interventions – huddles to improve identification of patients at risk for CLABSI, leadership safety rounds, partnership with the vascular access team, and hospital-acquired condition (HAC) rounding cards to prompt discussions on central line functionality. This multimodal approach led to a significant reduction in CLABSI rates between 2020 and 2021, and an increase in CLABSI-free days.
Birkeli GH, Ballangrud R, Jacobsen HK, et al. BMJ Open Qual. 2023;12:e002247.
Interprofessional huddles and voluntary reporting of incidents and near-misses are ways to improve patient safety and safety culture. This Norwegian post-anesthesia care unit (PACU) implemented a voluntary incident reporting method, Green Cross (GC), that includes daily team huddles to discuss reports from the previous 24 hours. Three years after implementation, staff reported GC was still active, but use has declined, particularly during the COVID-19 pandemic. They also reported a desire for increased follow up and physician involvement.
Cifra CL, Custer JW, Smith CM, et al. Crit Care Med. 2023;51:1492-1501.
Diagnostic errors remain a major healthcare concern. This study was a retrospective record review of 882 pediatric intensive care unit (PICU) patients to identify diagnostic errors using the Revised Safer Dx tool. Diagnostic errors were found in 13 (1.5%) patients, most commonly associated with atypical presentation and diagnostic uncertainty at admission.
Pfeiffer Y, Atkinson A, Maag J, et al. J Patient Saf. 2023;19:264-270.
Surgical site infections (SSI) are a common, but preventable, complication following surgery. This study sought to determine the association of commitment to, knowledge of, and social norms surrounding SSI prevention efforts and safety climate strength and level. Based on responses from nearly 2,800 operating room personnel in Sweden, only commitment and social norms were associated with safety climate level. None were associated with safety climate strength.
Sedney CL, Dekeseredy P, Singh SA, et al. J Pain Symptom Manage. 2023;65:553-561.
Health professional stigma and bias towards patients with substance use disorders can impede the delivery of effective healthcare. In this qualitative analysis of medical records for 25 patients with opioid use disorder, researchers identified several markers of stigma which can impact care, including blame and stereotyping.
Tataei A, Rahimi B, Afshar HL, et al. BMC Health Serv Res. 2023;23:527.
Patient handoffs present opportunities for miscommunication and errors. This quasi-experimental study examined the impact of an electronic nursing handover system (ENHS) on patient safety and handover quality among patients both with and without COVID-19 in the intensive care unit (ICU). Findings indicate that the ENHS improved the quality of the handover, reduced handover time, and increased patient safety.
D’Angelo A-LD, Kapur N, Kelley SR, et al. Surgery. 2023;174:222-228.
Prior research has asked surgeons how they cope with intraoperative errors, but this study asks operating room personnel how they perceive surgeons' coping strategies. Positive response strategies included announcing that an error has occurred and the plan for managing it. Negative responses include the surgeon becoming visibly upset, raising their voice, and blaming others. The authors suggest additional education on positive strategies to cope with errors during medical education and residency.
Vaughan-Malloy AM, Chan Yuen J, Sandora TJ. Am J Infect Control. 2023;51:514-519.
Hand hygiene adherence is an essential component of patient safety. Using the SEIPS 2.0 model, this study explored clinician perspectives about high reliability in hand hygiene. The 61 respondents identified several barriers associated with aspects of organizational culture, environment, tasks and tools, including frequently empty alcohol-based hand rub dispensers and challenges with the layout of patient care areas.
No results.
Lalani M, Wytrykowski S, Hogan H. BMJ Open. 2023;13:e067441.
Care integration —the linking of care across primary, secondary, social, community, and mental health—can improve care for patients with chronic conditions. In this review, 24 studies of integrated care were included. Most of the studies focused on decreasing risk of falls and/or medication errors, mostly in the home or across settings (e.g., hospital and primary care). The authors recommend future research focus on safety targets beyond falls and medication safety and report on outcomes.
Chen H-W, Wu J-C, Kang Y-N, et al. Nurse Educ Today. 2023;126:105831.
Patient safety can be improved when all staff feel empowered to speak up about errors. In this systematic review, the authors identified 11 studies on the effectiveness of trainings to increase nurses' assertiveness to report medical errors. Interventions resulted in significant improvement in nurses' speaking up behavior, but not their attitude or confidence after training. Structured content, use of multiple teaching approaches, and adequate training time were critical to significant improvement.
Loncharich MF, Robbins RC, Durning SJ, et al. Diagnosis (Berl). 2023;10:205-214.
Cognitive biases, such as heuristics, help clinicians make rapid decisions, but these biases can result in errors. This review sought to explore biases in internal medicine, the impact of biases on patient outcomes, and the effect of debiasing strategies. Forty-one biases were studied, and debiasing strategies showed little to no effect on reducing bias.
Scholliers A, Cornelis S, Tosi M, et al. Br J Anaesth. 2023;130:622-635.
Clinicians often work long hours with irregular schedules, which can contribute to fatigue. This scoping review of 30 studies identified several patient safety risks associated with fatigue in anesthesia providers, including deterioration in non-technical skills, increased medication errors, poor attention and psychomotor decline.
Sparling J, Hong Mershon B, Abraham J. Jt Comm J Qual Patient Saf. 2023;49:410-421.
Multiple handoffs can occur during perioperative care, which can increase the risk for errors and patient harm. This narrative review summarizes research on the benefits, limitations, and implementation challenges of electronic tools for perioperative handoffs and the role of artificial intelligence (AI) and machine learning (ML) in perioperative care.
Denecke K. Stud Health Technol Inform. 2023;302:157-161.
The public is increasingly using conversational assistants like Siri, Alexa, and Google Assistant to find medical advice and self-diagnose. This narrative review summarizes three facets of safety: system (data privacy/security), patient (risks of acting on inaccurate information), and perceived (patient trust in the system). Future research should address all three safety facets, and the results should be transparent to consumers.
No results.
Grant Recipient
Rockville, MD: Agency for Healthcare Research and Quality; 2023.
The Agency for Healthcare Research and Quality (AHRQ) offers many practical tools and resources to help healthcare organizations, providers, and others make patient care safer These tools are based on research, and they can assist staff in hospitals, emergency departments, long-term care facilities, and ambulatory settings to prevent avoidable complications of care. The purpose of this challenge is to elicit new narratives of how AHRQ toolkits are being used. The winners of the competition are University of Missouri, University of Chicago Medicine and Chesapeake Regional Healthcare.
Department of Health and Social Care. London, England: Crown Copyright; 2023
Following an investigation into the death of 11-month-old Elizabeth Dixon in the UK’s National Health System (NHS), a report with 12 recommendations for system improvement was released. This report sets out the government’s response to each recommendation, including the agency responsible for each recommendation, where applicable.
Newspaper/Magazine Article
Conn R, Fox A, Carrington A, et al. Pharmaceutical Journal. 2023;310:7973.
Children are particularly vulnerable to medication errors. Weight- and age-based dosing, different medication formulations, and miscommunication with parents and caregivers contribute to errors. Data-driven education and peer feedback have been noted as effective strategies to reduce prescribing errors.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute care edition. June 1, 2023; 28(11):1-6.
Oxytocin, which is commonly used to induce labor, has been associated with adverse events. Based on 2,073 oxytocin-related medication errors reported to one patient safety organization, the authors of this article summarize the common event types (e.g., pump misprogramming, incorrect infusion set-up, or use of incorrect drug or concentration) and highlight several recommendations to increase safe oxytocin administration.
Audiovisual
Sheridan S. Turn on the Lights. Institute for Healthcare Improvement. May 2023
Patient engagement is an important component in patient safety. This episode from the Turn on the Lights podcast (hosted by Institute for Healthcare Improvement leaders Don Berwick, MD and Kedar Mate, MD) features a discussion with Sue Sheridan from Patients for Patient Safety US about the importance of involving patients and patient perspectives in the development of patient safety solutions.
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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