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July 5, 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
Black GB, Boswell L, Harris J, et al. Prim Health Care Res Dev. 2023;24:e26.
Delayed cancer diagnosis is a major contributor to suboptimal outcomes and malpractice claims. In this review, factors contributing to delayed diagnosis of blood cancers are explored. Initial delays resulted from patients’ non-specific symptoms such as fatigue and symptoms that came and went. After seeking care, factors contributing to delayed diagnosis include seeing a locum general practitioner, being Black or a woman, and having multiple chronic conditions.
Riester MR, Goyal P, Steinman MA, et al. J Gen Intern Med. 2023;38:1563-1566.
Potentially inappropriate medication (PIM) prescribing in older adults is common and can lead to medication-related harm. This retrospective study of Medicare beneficiaries estimated that the prevalence of PIM use was 77% among long-stay nursing home residents (defined as >101 consecutive days in a nursing home). The most common PIMs were benzodiazepines, antipsychotics, and insulin.
Shin P, Desai V, Conte AH, et al. Perm J. 2023;27:160-168.
Burnout among healthcare workers is widespread and can threaten patient safety. This article summarizes the individual, organizational, and culture factors contributing to perioperative physician burnout, how burnout impacts surgical patient care, and strategies to mitigate perioperative physician burnout.
Michelson KA, McGarghan FLE, Patterson EE, et al. Diagnosis (Berl). 2023;10:183-186.
Delayed diagnosis of appendicitis can lead to serious patient harm. This study of 7,452 pediatric patients with appendicitis found that delayed diagnosis occurred in 1.4% of cases and increased clinician use of blood tests decreased the likelihood of delayed diagnosis.
Venesoja A, Tella S, Castrén M, et al. BMJ Open. 2023;13:e067754.
Emergency medical services (EMS) personnel encounter unique safety challenges when delivering patient care. Using focus groups and individual interviews with EMS medical directors and managers in Finland, this qualitative study explored perceptions around patient collaboration to improve safety in EMS. Participants agreed that patient safety is an organizational responsibility and management should provide EMS patients with opportunities to speak up as well as address barriers to voicing concerns.
Albutt AK, Ramsey L, Fylan B, et al. Health Expect. 2023;26:1467-1477.
Patients' healthcare-seeking behaviors changed during the COVID-19 pandemic, particularly during the first wave. This longitudinal study sought patient perspectives about their experiences accessing healthcare, activities they undertook to keep themselves and others safe, and their understanding of healthcare system resilience and resources. Three themes emerged: a "new safety normal," existing vulnerabilities and heightened safety, and "are we all in this together?" The study highlighted that preexisting gaps in care experienced by those with chronic conditions or other vulnerabilities widened during the pandemic and deserve further research.
Roberts M. Br J Nurs. 2023;32:508-513.
Preventing inpatient falls is a patient safety target. This study used one health system’s incident reporting tool in the United Kingdom to ascertain the incidence and characteristics of inpatient falls among patients under 1:1 or “cohorting” supervision. Findings indicate that nearly one in five falls occurred while the patient was under enhanced supervision and most commonly occurred in the patient’s bathroom or bedside.
Ekstedt M, Nordheim ES, Hellström A, et al. BMC Health Serv Res. 2023;23:581.
Remote patient monitoring (RPM) allows patients to remain in their homes while still receiving disease management. This study involved patients with chronic conditions who were receiving RPM and clinicians (nurses and physicians) who were providing RPM. Clinicians described the importance of knowing patients' level of health literacy and ensuring they understand when someone is reviewing their remote data (e.g., not on weekends). Patients reported feeling more confident, knowing someone was checking on them weekly. Overall, both groups had positive perceptions of patient safety.
Riester MR, Goyal P, Steinman MA, et al. J Gen Intern Med. 2023;38:1563-1566.
Potentially inappropriate medication (PIM) prescribing in older adults is common and can lead to medication-related harm. This retrospective study of Medicare beneficiaries estimated that the prevalence of PIM use was 77% among long-stay nursing home residents (defined as >101 consecutive days in a nursing home). The most common PIMs were benzodiazepines, antipsychotics, and insulin.
Conn Busch J, Wu J, Anglade E, et al. Jt Comm J Qual Patient Saf. 2023;49:365-372.
Structured handoffs are recognized as a method to ensure that complete, accurate information is shared between teams. This article describes the impact of the Handoffs and Transitions in Critical Care (HATRICC) study on accuracy and completeness of handoff before and after implementation of a structured handoff tool. Post-intervention, the accuracy and completeness of handoffs improved. Omissions, mortality, and length of intensive care unit (ICU) stay were reported in a 2019 study.
Langlieb ME, Sharma P, Hocevar M, et al. J Patient Saf. 2023;19:375-378.
Preventable adverse events can lead to serious patient harm and financial burden for individuals and organizations. Building off prior research estimating the incidence of perioperative medication errors, these researchers performed a systematic review to identify and quantify the downstream costs and patient harm due to medication errors. The researchers estimated that the total additional annual cost of care due to perioperative medication errors was $5.33 billion dollars.
Ališić E, Krupić M, Alić J, et al. Cureus. 2023;15:e38854.
The World Health Organization's (WHO) Surgical Safety Checklist (SSC) has resulted in improved surgical outcomes; however, use of the checklist varies. In this study, surgical personnel (surgeons, anesthesiologists, nurse anesthetists, surgical nurses, and assistant nurses) were surveyed about use of the SCC in their hospital, including who was responsible for ensuring its use. Although most groups reported it was not clear who was responsible for implementing the SSC prior to surgery, they believed it was the assistant nurse.
Khan WU, Seto E. J Med Internet Res. 2023;25:e43386.
Artificial intelligence (AI) and machine learning (ML) are emerging as tools to improve patient care, but they are not without risks. This article proposes use of a safety checklist to determine readiness to launch AI technologies, prompting users to consider physical and mental health and economic and social risks and benefits.
Gallagher TH, Hemmelgarn C, Benjamin EM. BMJ Qual Saf. 2023;32:557-561.
Numerous organizations promote communication with patients and families after harm has occurred due to medical error. This commentary reflects on perceived barriers to patient disclosure and describes the patient and family perspectives and needs following harm. The authors promote the use of Communication and Resolution Programs (CRP) such as the learning community Pathway to Accountability, Compassion, and Transparency (PACT) to advance research, policy, and transparency regarding patient harm.
Shin P, Desai V, Conte AH, et al. Perm J. 2023;27:160-168.
Burnout among healthcare workers is widespread and can threaten patient safety. This article summarizes the individual, organizational, and culture factors contributing to perioperative physician burnout, how burnout impacts surgical patient care, and strategies to mitigate perioperative physician burnout.
Dudley KA. AORN J. 2023;117:399-402.
Root cause analysis (RCA) may not be an ideal process, but it still creates opportunities for learning and improvement after a sentinel event. This article posits why perioperative nurses may not report problems to avoid engagement in RCA activities. Increasing nurse awareness of RCA as a multidisciplinary and systems-focused improvement method is a suggested educational tactic to increase nurse RCA participation.
Xue Qin QN, Ming LC, Abd Wahab MS, et al. Res Social Adm Pharm. 2023;19:873-881.
Medication-related problems (including adverse drug events, medication errors, and potentially inappropriate prescribing) among patients with dementia or cognitive impairment can contribute to functional decline and poor outcomes. This systematic review of 15 studies found that the prevalence of medication-related problems among patients with dementia or cognitive impairments varied widely, from 9.1% to 83.6%.
Kim RG, An VVG, Lee SLK, et al. Orthop Traumatol Surg Res. 2023;109:103299.
Overlapping surgery, where “critical” portions of surgery are performed sequentially in separate operating rooms, is used to increase efficiency and number of procedures performed each day. This systematic review and meta-analysis was performed to determine differences in risk of complications between overlapping surgery (OS) and non-overlapping surgery (NOS) in total hip and total knee arthroplasty. Consistent with prior studies and reviews, there were no significant differences in adverse events or complications between OS and NOS. The authors stress that informed consent and patient education prior to OS is critically important.
Black GB, Boswell L, Harris J, et al. Prim Health Care Res Dev. 2023;24:e26.
Delayed cancer diagnosis is a major contributor to suboptimal outcomes and malpractice claims. In this review, factors contributing to delayed diagnosis of blood cancers are explored. Initial delays resulted from patients’ non-specific symptoms such as fatigue and symptoms that came and went. After seeking care, factors contributing to delayed diagnosis include seeing a locum general practitioner, being Black or a woman, and having multiple chronic conditions.
Audiovisual Presentation
Committee on Unequal Treatment, National Academies. 2023.
Health disparities and unequal care contribute to patient and family harm. This 3-component workshop series explored ethnic and racial disparities in health care. A November workshop revisited the findings from the three sessions.
Washington DC: Department of Veterans Affairs, Office of Inspector General; May 10, 2023. Report no. 22-01116-110.
Death of a patient by suicide is a sentinel event. This report examined one incident and identified care deficiencies associated with lack of mental health referrals and pain management follow-up. In addition, post-event process gaps occurred, impacting learning and resolution such as a delay in the inquiry launch, peer review, and clinical review of the incident. Claims that the facility purposely sought to hide information that the suicide happened were unsubstantiated.
Newspaper/Magazine Article
Allen A. KFF Health News. June 21, 2023.
A variety of supply-chain, quality control, and economic factors complicate access to medications due to drug shortages that put patients at risk. This article discusses specific systemic weaknesses in the drug development process that are reducing the safety of cancer medication therapy in the United States.
Newspaper/Magazine Article
Gammon K. STAT. June 26, 2023.
The maternal mental health crisis results in harm to mothers and their families. This article discusses systemic issues that impact the safe psychological care of mothers from pregnancy through the years of caring for toddlers. Lack of timely diagnosis is a major consideration discussed.
This Month’s WebM&Ms
WebM&M Cases
Sean Flynn, MD and David K. Barnes, MD, FACEP |
A 56-year-old woman presented to the emergency department (ED) with shaking, weakness, poor oral intake and weight loss, constipation for several days, subjective fevers at home, and mild pain in the chest, back and abdomen. An abdominal x-ray confirmed a large amount of stool in the colon with no free air and her blood leukocyte count was 11,500 cells/μL with 31% bands. She received intravenous fluids but without any fecal output while in the ED. She was discharged to home with a diagnosis of constipation, dehydration and failure to thrive and planned follow-up with her primary care provider. Three days later, she was admitted to a second hospital and the surgeon found stercoral colitis and a large perforated “stercoral ulcer” of the proximal sigmoid colon with disseminated fecal and purulent material. Despite aggressive surgical and postoperative care, she expired from sepsis ten days later. The commentary summarizes the diagnosis and management of stercoral colitis and the importance of prompt identification of bandemia, which should trigger further investigation for an underlying infection.
WebM&M Cases
Spotlight Case
Theresa Duong, MD, Noelle Boctor, MD, and James Bourgeois, OD, MD |
This case describes a 65-year-old man with alcohol use disorder who presented to a hospital 36 hours after his last alcoholic drink and was found to be in severe alcohol withdrawal. The patient’s Clinical Institute Withdrawal Assessment (CIWA) score was very high, indicating signs and symptoms of severe alcohol withdrawal. He was treated with symptom-triggered dosing of benzodiazepines utilizing the CIWA protocol and dexmedetomidine continuous infusion. The treating team had planned to wean the infusion; however, the following day, the patient was noted to be obtunded on a high dose of dexmedetomidine. He remained somnolent for two additional days and subsequently developed aspiration pneumonia and Clostridioides difficile colitis, which further prolonged his hospital stay and strained relationships among the patient's family, the nursing staff and medical team. The commentary reviews the medications commonly used to treat alcohol withdrawal and the risks associated with these medications, the use of standardized medication order sets for continuous weight-based infusions within the intensive care unit, and ways to minimize clinician bias in assessing and treating substance use disorders.
WebM&M Cases
Christian Bohringer, MBBS, James Bourgeois, OD, MD, Glen Xiong, MD, and Emily Wei, MD |
A 50-year-old unhoused patient presented to the Emergency Department (ED) for evaluation of abdominal pain, reportedly one day after swallowing multiple sharp objects. Based on the radiologic finding of an open safety pin or paper clip in the distal stomach, he was appropriately scheduled for urgent esophagogastroduodenoscopy and ordered to remain NPO (nothing by mouth) to reduce the risk of aspirating gastric contents. However, the order was not communicated verbally and he was allowed to eat, leading to postponement of the procedure and ultimately to an unsatisfactory conclusion with discharge of the patient against medical advice. This case raises interesting questions about the evaluation and treatment of pica in the ED, the communication of dietary status information, the risks of procedural sedation in a non-fasting patient, and the evaluation of decisional capacity in a patient with recurrent pica.
This Month’s Perspectives
Interview
Regina M. Hoffman, MBA, RN, Cindy Manaoat Van, MHSA, CPPS,Sarah E. Mossburg, RN, PhD |
Regina Hoffman is the executive director of the Pennsylvania Patient Safety Authority. We spoke to her about her experience in collaborative learning, sharing information across healthcare facilities, and patient safety education.
Perspectives on Safety
Regina M. Hoffman, MBA, RN, Cindy Manaoat Van, MHSA, CPPS, Sarah E. Mossburg, RN, PhD |
This piece focuses on the importance of building the capacity of the workforce and organizations for patient safety using patient safety education.
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