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June 28, 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
Alanazi FK, Lapkin S, Molloy L, et al. J Clin Nurs. 2023;32:7260-7272.
Patient fall rates can be impacted by numerous factors, such as staffing, safety culture, and individual nurse safety attitudes. In this study of 619 hospital nurses, a strong safety climate, good working conditions, and lower rates of self-reported missed care were associated with a lower incidence of inpatient falls. Additionally, good collaboration between nurses, physicians, and pharmacists was associated with lower fall rates.
Congdon M, Rauch B, Carroll B, et al. Hosp Pediatr. 2023;13:563-571.
Diagnostic errors in pediatrics remain a significant focus of patient safety. This study uses two years of unplanned readmissions to a children’s hospital to identify missed opportunities for improving diagnosis (MOID). Clinician decision-making and diagnostic reasoning were identified as key factors for MOID. The authors recommend that future research include larger cohorts to identify populations and conditions at increased risk for MOID-related readmissions.
Yang CJ, Saggar V, Seneviratne N, et al. Jt Comm J Qual Patient Saf. 2023;49:297-305.
Simulation training is commonly used by hospitals to identify threats to safety and improve patient care. This article describes the development and implementation of an in situ simulation to improve acute airway management during the COVID-19 pandemic across five emergency departments. The simulation protocol helped identify latent safety threats involving equipment, infection control, and communication. The simulation process also helped staff identify interventions to reduce latent safety threats, including improved accessibility of airway management equipment, a designated infection control cart, and role identification cards to improve team function.
Schrøder K, Assing Hvidt E. Int J Environ Res Public Health. 2023;20:5749.
Healthcare providers may experience emotional distress after involvement in an adverse or traumatic event. This qualitative study with 198 healthcare professionals identified common emotions experienced after adverse events as well as the types of support needed after involvement in an adverse event. These findings can contribute to the development and refinement of support programs for healthcare workers after adverse events.
Browne C, Crone L, O'Connor E. J Surg Educ. 2023;80:864-872.
While medical trainees and residents agree that disclosing errors to patients is important, they also perceive barriers to doing so. In this study, surgical trainees described factors influencing their decisions not to disclose errors despite their intention to do so. Even with formal communication trainings throughout the program, participants reported a lack of sufficient education in error disclosure. Workplace culture and role-modelling influenced their own disclosure practices both positively and negatively.
Yang CJ, Saggar V, Seneviratne N, et al. Jt Comm J Qual Patient Saf. 2023;49:297-305.
Simulation training is commonly used by hospitals to identify threats to safety and improve patient care. This article describes the development and implementation of an in situ simulation to improve acute airway management during the COVID-19 pandemic across five emergency departments. The simulation protocol helped identify latent safety threats involving equipment, infection control, and communication. The simulation process also helped staff identify interventions to reduce latent safety threats, including improved accessibility of airway management equipment, a designated infection control cart, and role identification cards to improve team function.
Chang C, Varghese N, Machiorlatti M. Diagnosis (Berl). 2023;10:105-109.
Clerkship directors indicate clinical and diagnostic reasoning education should be included in medical school curricula, but up to half of programs do not offer it. This article describes the development, implementation, and evaluation of a diagnostic reasoning virtual training for pre-clinical medical students. Students reported increased confidence and understanding of diagnostic reasoning.
Øyri SF, Søreide K, Søreide E, et al. BMJ Open Qual. 2023;12:e002368.
Reporting and learning from adverse events are core components of patient safety. In this qualitative study involving 15 surgeons from four academic hospitals in Norway, researchers identified several individual and structural factors influencing serious adverse events as well as both positive and negative implications of transparency regarding adverse events. The authors highlight the importance of systemic learning and structural changes to foster psychological safety and create space for safe discussions after adverse events.
Congdon M, Rauch B, Carroll B, et al. Hosp Pediatr. 2023;13:563-571.
Diagnostic errors in pediatrics remain a significant focus of patient safety. This study uses two years of unplanned readmissions to a children’s hospital to identify missed opportunities for improving diagnosis (MOID). Clinician decision-making and diagnostic reasoning were identified as key factors for MOID. The authors recommend that future research include larger cohorts to identify populations and conditions at increased risk for MOID-related readmissions.
Cortegiani A, Ippolito M, Lakbar I, et al. Eur J Anaesthesiol. 2023;40:326-333.
A simulation study in 2017 showed anesthesia residents performed worse when sleep-deprived after working a night shift. In this quantitative study of more than 5,000 European anesthesiologists, participants reported that working night shifts reduced their quality of life and put their patients at risk. Few reported institutional support (e.g., training, fatigue monitoring) for night shift workers. Importantly, this study reports on perceived risk to patients, not actual patient risk.
Alanazi FK, Lapkin S, Molloy L, et al. J Clin Nurs. 2023;32:7260-7272.
Patient fall rates can be impacted by numerous factors, such as staffing, safety culture, and individual nurse safety attitudes. In this study of 619 hospital nurses, a strong safety climate, good working conditions, and lower rates of self-reported missed care were associated with a lower incidence of inpatient falls. Additionally, good collaboration between nurses, physicians, and pharmacists was associated with lower fall rates.
Carthey J. BMJ Qual Saf. 2023;32:441-443.
The Measurement and Monitoring of Safety Framework (MMSF) draws on principles of high-reliability to increase patient safety at the organizational level. This commentary describes the Canadian Learning Collaborative’s experience implementing MMSF and highlights several key elements for successful implementation.
Ye J. JMIR Periop Med. 2023;6:e34453.
Perioperative medication errors are common. This article highlights several interventions to reduce the risk of perioperative medication errors, including improved medication labeling, adoption of artificial intelligence for decision support and risk prediction, and the use of health information technology (IT), such as computerized physician order entry (CPOE), electronic medication administration records (eMAR), and barcode medication administration (BCMA).
Pisani AR, Boudreaux ED. Focus (Am Psychiatr Publ). 2023;21:152-159.
Identifying patients with suicidal ideation can be a challenging clinical problem in the emergency department. These authors use a systems-based approach to identify missed opportunities to prevent suicide and present a systems approach to suicide prevention including three core domains – a culture of safety and prevention, applying best practices and policies for prevention in systems, and workforce education and development.
Kelen GD, Kaji AH, Schreyer KE, et al. Ann Emerg Med. 2023;82:336-340.
In December 2022, AHRQ released Diagnostic Errors in the Emergency Department: a Systematic Review which received extensive coverage in both academic publications and the national media. This peer-reviewed commentary asserts emergency department (ED) overcrowding is a greater safety risk than misdiagnosis, and errors are more frequently systemic rather than cognitive.
Lainidi O, Jendeby MK, Montgomery A, et al. Front Psychiatry. 2023;14:111579.
Encouraging frontline healthcare workers to voice concerns is an important component of safety culture. This systematic review of 76 qualitative studies explored how speaking up behaviors and silence are measured in healthcare. The authors identified several evidence gaps, including a reliance on self-reported data and overrepresentation of certain demographic characteristics.
Klemann D, Rijkx M, Mertens H, et al. Healthcare (Basel). 2023;11:1636.
Reducing maternal morbidity and mortality is a global patient safety goal. This systematic review identified three categories of direct and indirect risk factors of maternal safety: delay of care, coordination and management of care, and scarcity of supply, personnel, and knowledge. The risk factors varied between developed and developing countries.
Short A, McPeake J, Andonovic M, et al. Eur J Hosp Pharm. 2023;30:250-256.
Critical care patients may be vulnerable to medication errors due to the complex nature of the intensive care unit (ICU). This systematic review of 47 studies found that as many as 80% of patients on critical care services experienced medication-related problems after discharge from the hospital. Common problems include inappropriate continuation of newly-prescribed medications as well as discontinuation of chronic disease medications.
Ayre MJ, Lewis PJ, Keers RN. BMC Psychiatry. 2023;23:417.
Medication safety in inpatient and outpatient settings is a major focus of patient safety efforts. This review included 79 studies on epidemiology, etiology, or interventions related to psychiatric medication safety in primary care (e.g., general practice, community pharmacy, long-term care). Most studies focused on older adults and potentially inappropriate prescribing. The authors recommend future research on wider age groups and underrepresented mental health diagnosis, such as attention deficient hyperactivity disorder (ADHD).
No results.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute care edition. June 15, 2023;28(12);1-5.
Pediatric patients are at increased risk of adverse drug events due to weight- and age-based dosing. This article describes additional risk in non-pediatric settings, such as providers’ lack of familiarity with dosing regimens or lack of access to pediatric equipment. Recommendations to reduce risks include appointing pediatric coordinators, designating space for pediatric patients when possible, and collaborating with pediatric institutions to create protocols for care and transfer.
Book/Report
Chicago, IL: American Hospital Association: May 2023.
Healthcare-acquired infections (HAIs) are a common complication of hospital care. This report summarizes lessons learned at a series of infection prevention and control listening sessions. Challenges, opportunities for improvement, and impacts of COVID-19, both positive and negative, are presented.
Santhosh L, Cornell E, Rojas JC, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2023. AHRQ Publication No. 23-0040-1-EF.
Care transitions present opportunities for errors. This issue brief highlights the risk of diagnostic errors during transitions in care, such as from the emergency department to the inpatient floor or from inpatient to outpatient care. The brief describes strategies to prevent and reduce these errors, such as diagnostic feedback or structured handoff tools.
Newspaper/Magazine Article
Blau M. ProPublica. June 14, 2023.
Medical errors during organ transplants can have catastrophic consequences. This report describes the errors that contributed to failed transplants and patient deaths at one liver transplant center and the organizational-level factors that allowed these errors to continue for several years.
Press Release/Announcement
May 31, 2023; Fed Register;88:35694-35728.
Standardized medication labels have been shown to increase patient comprehension and adherence. The Food and Drug Administration (FDA) is proposing a rule which, if approved, would require an easily understandable, one-page medication guide be given to patients when receiving medication in the outpatient setting. Written comments may be submitted through November 27, 2023.
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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