Email Updates
June 21, 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
Choi JJ, Durning SJ. Diagnosis (Berl). 2023;10:89-95.
Context (e.g., patient characteristics, setting) can influence clinical reasoning and increase the risk for diagnostic errors. This article explores the ways in which individual-, team-, and system-level contextual factors impact reasoning, clinician performance and risk of error. The authors propose a multilevel framework to better understand how contextual factors impact clinical reasoning.
Murphy DR, Zimolzak AJ, Upadhyay DK, et al. J Am Med Inform Assoc. 2023;30:1526-1531.
Measuring diagnostic performance is essential to identifying opportunities for improvement. In this study, researchers developed and evaluated two electronic clinical quality measures (eCQMs) to assess the quality of colorectal and lung cancer diagnosis. Each measure used data from the electronic health record (EHR) to identify abnormal test results, evidence of appropriate follow-up, and exclusions that signified unnecessary follow-up. The authors describe the measure testing results and outline the challenges in working with unstructured EHR data.
Turley N, Elam M, Brindle ME. JAMA Netw Open. 2023;6:e2317183.
The WHO Surgical Safety Checklist (SSC) has been widely implemented in surgical settings across the globe. This qualitative study examined surgical team member experience regarding modifications to the SSC in hospitals in high-income countries. Respondents supported routine review of SSCs to ensure they are modified and updated to address local issues and standards of practice and noted that the modification process can improve team cohesion and SSC buy-in.
Gangopadhyaya A, Pugazhendhi A, Austin M et al. Washington DC: Leapfrog Group; 2023.
Adverse events in patients of color continue to be connected with systematic racism and biases. This report summarizes the distribution of patient safety events among Black and Hispanic patients across 2,019 Leapfrog patient safety graded hospitals and found that they experience adverse surgical events at a higher level than white patients.
Jain A, Brooks JR, Alford CC, et al. JAMA Health Forum. 2023;4:e231197.
Algorithms are commonly used to guide clinical decision-making, but concerns have been raised regarding bias due to the use of race-based data. This qualitative analysis examined perspectives of 42 stakeholders (e.g., individuals, representatives from clinical professional societies or payers, etc.) regarding the use of race- and ethnicity-based algorithms in healthcare. Seven themes were identified, highlighting concerns regarding bias, algorithm transparency, lack of standardization regarding how race and social determinants are collected and defined, and the use of a social construct as a proxy in clinical decision-making.
Murphy DR, Zimolzak AJ, Upadhyay DK, et al. J Am Med Inform Assoc. 2023;30:1526-1531.
Measuring diagnostic performance is essential to identifying opportunities for improvement. In this study, researchers developed and evaluated two electronic clinical quality measures (eCQMs) to assess the quality of colorectal and lung cancer diagnosis. Each measure used data from the electronic health record (EHR) to identify abnormal test results, evidence of appropriate follow-up, and exclusions that signified unnecessary follow-up. The authors describe the measure testing results and outline the challenges in working with unstructured EHR data.
Wolf M, Rolf J, Nelson D, et al. Hosp Pharm. 2023;58:309-314.
Medication administration is a complex process and is a common source of preventable patient harm. This retrospective chart review of 145 surgical patients over a two-month period found that 98.6% of cases involved a potential medication error, most frequently due to potential dose omissions and involving vasopressors, opioids, or neuromuscular blockers.
Kennedy GAL, Pedram S, Sanzone S. Safety Sci. 2023;165:106200.
Simulation training is an important component of medical education. In this study, researchers compared the impact of traditional clinical skills training with or without interactive virtual reality (VR) on human error among medical students performing arterial blood gas collection. Findings indicate that students who participated in VR-based clinical skills training were less likely to commit errors during simulated practical exam compared to students who did not participate in VR-based training.
Turley N, Elam M, Brindle ME. JAMA Netw Open. 2023;6:e2317183.
The WHO Surgical Safety Checklist (SSC) has been widely implemented in surgical settings across the globe. This qualitative study examined surgical team member experience regarding modifications to the SSC in hospitals in high-income countries. Respondents supported routine review of SSCs to ensure they are modified and updated to address local issues and standards of practice and noted that the modification process can improve team cohesion and SSC buy-in.
Petrino R, Tuunainen E, Bruzzone G, et al. Eur J Emerg Med. 2023;30:280-286.
The emergency department is a busy and complex environment that can present challenges to patient safety. This survey of emergency medicine professionals from 101 countries identified several patient safety concerns, including workflow and staffing, overcrowding and perceived lack of leadership support. Two PSNet WebM&M commentaries highlight the impact of boarding and overcrowding in the emergency department on patients with a postoperative infection and ruptured abdominal aortic aneurysm.
Ming Y, Meehan R. J Patient Saf. 2023;19:369-374.
Health care workers’ perception of safety is an important indicator of safety culture. Using data from the 2021 AHRQ Hospital Survey on Patient Safety Culture™ (SOPS®), these researchers examined individual and organizational factors influencing perceived patient safety ratings. Findings indicate that nurses have lower patient safety perceptions compared to other job types and that organizational factors such as organizational learning, leadership support, and ease of handoffs and information exchange, were all associated with higher perceived patient safety.
Grailey K, Lound A, Murray E, et al. PLoS One. 2023;18:e0286796.
Effective teamwork is critical in healthcare settings. This qualitative study explored experiences with personality, psychological safety and perceived stressors among emergency and critical care department staff working in the United Kingdom. Findings underscore the ways in which personality traits can influence team performance.
Wolf MS, Smith K, Basu M, et al. J Pediatr Intensive Care. 2023;12:125-130.
Preventable harm continues to occur in high-risk care environments such as the pediatric intensive care unit (ICU). In this survey of 266 clinicians within a large pediatric healthcare system, 42% reported experiencing psychological distress after an adverse event, 22% reported absenteeism and 23% reported considering leaving the ICU. After involvement in an adverse event, respondents said that they would prefer peer support and the ability to step away from the unit to recover.
Saint S, Greene MT, Krein SL, et al. Infect Control Hosp Epidemiol. 2023;44:1913-1919.
The COVID-19 pandemic challenged infection prevention and control practices. Findings from this survey of infection prevention professionals from acute care hospitals in the United States found that while CLABSI and VAE preventive practices either increased or remained consistent, use of CAUTI preventive practices decreased during the pandemic.
Combs A, Klein VR. J Healthc Risk Manag. 2023;43:38-42.
Labor and delivery units are high-risk care environments. This article describes the development and implementation of a weekly obstetrics and gynecology Safety Call at one large health system. The Safety Call provides leadership across the 10 maternity hospitals an opportunity to promote proactive preparation, improve communication, increase situational awareness, and share safety concerns or other issues facing each hospital. Implementation of the Safety Call contributed to a 19% decrease in a composite measure of adverse events.
Sanfilippo JS, Kettering C, Smith SR. Clin Obstet Gynecol. 2023;66:293-297.
Effective apology for medical mistakes is a cornerstone for healing and improvement. This piece discusses the impact sincere and complete apologies may have on legal resolutions of patient harm. They discuss the current presence of apology laws at the state level and the limited role they play in protecting clinicians who err and apologize in a court of law.
Choi JJ, Durning SJ. Diagnosis (Berl). 2023;10:89-95.
Context (e.g., patient characteristics, setting) can influence clinical reasoning and increase the risk for diagnostic errors. This article explores the ways in which individual-, team-, and system-level contextual factors impact reasoning, clinician performance and risk of error. The authors propose a multilevel framework to better understand how contextual factors impact clinical reasoning.
Murray JS, Lee J, Larson S, et al. BMJ Open Qual. 2023;12:e002237.
A “just culture” balances organizational responsibility and individual accountability after an error occurs. This integrative review of 16 articles identified four concepts critical to implementing a “just culture” in healthcare settings – leadership commitment, education and training, accountability, and open communication.
Lee SE, Repsha C, Seo WJ, et al. Nurse Educ Today. 2023;126:105824.
“Horror room” simulations are used to help train medical students to identify patient safety hazards. This systematic review of 16 studies found that “horror room” simulations are more common in Western countries and focus on medication-related or procedure-related incidents. The authors highlight the need for research establishing parameters regarding the ideal size and composition of the team to yield the highest impact on learners.
Cohen TN, Kanji FF, Wang AS, et al. Am J Surg. 2023;226:315-321.
Intraoperative deaths are rare, catastrophic events. This retrospective review of 154 intraoperative deaths occurring between March 2010 and August 2022 at one academic medical center found that most deaths occurred during emergency procedures. Common contributing factors included coordination challenges, skill-based errors, and environmental factors.
Meeting/Conference Proceedings
National Academies of Health.
Delay in access to obstetric care hinders safe treatment for patients experiencing pregnancy complications. This webinar discussed a range of factors affected by abortion restrictions and reviewed options to ensuring safety given legal and other structural impediments. A written brief is forthcoming.
Newspaper/Magazine Article
Levi R, Gorenstein D. Health Shots. National Public Radio. June 6, 2023.
Systemic biases are present in data tools, training and culture across health care. This article discusses weaknesses in artificial intelligence algorithms that are poised to further entrench biases and inequities into health care systems. The authors highlight the role of regulators and industry in combating the presence of biases in decision making technologies.
Press Release/Announcement
Institute for Safe Medication Practices. February 2024.
The integration of best practices into daily work is an indication of their usefulness and sustainability. This survey seeks to understand the broad use of 2024-2025 Targeted Medication Safety Best Practices for Hospitals throughout health care to determine implementation successes and barriers. Data submission for this collection cycle closes April 19, 2024.
Newspaper/Magazine Article
Smith MJ. Anesthesiology News. June 6, 2023.
The use of office-based anesthesia presents both care improvements and risks for patients and clinical teams. This article summarizes frontline concerns regarding the use of non–operating room anesthesia and highlights improved team communication, forcing functions, feedback systems and measurement as tactics to enhance safety.
Gangopadhyaya A, Pugazhendhi A, Austin M et al. Washington DC: Leapfrog Group; 2023.
Adverse events in patients of color continue to be connected with systematic racism and biases. This report summarizes the distribution of patient safety events among Black and Hispanic patients across 2,019 Leapfrog patient safety graded hospitals and found that they experience adverse surgical events at a higher level than white 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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