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July 19, 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
Aiken LH, Lasater KB, Sloane DM, et al. JAMA Health Forum. 2023;4(7):e231809.
While the association between clinician burnout and patient safety are not new, the COVID-19 pandemic brought this safety concern back to the forefront. In this study conducted at 60 US Magnet hospitals, nurses and physicians reported high levels of burnout and rated their hospital unfavorably on patient safety. Increased nurse staffing was the top recommendation to reduce burnout with less emphasis on wellness and resilience programs.
Goodwin G, Marra E, Ramdin C, et al. Am J Emerg Med. 2023;70:90-95.
When the US Supreme Court overturned Roe v. Wade, access to safe reproductive care was restricted even for patients with wanted or non-viable pregnancies. This study describes trends in early pregnancy-related emergency department visits prior to the court decision and how new restrictions have resulted in physician uncertainty and delays in care in states with abortion bans. The authors recommend physicians be mindful of Emergency Medical Treatment and Active Labor Act (EMTALA) when caring for pregnant individuals in the emergency department.
Pradeda AM, Pérez MSA, Oliveira CF, et al. Farm Hosp. 2023;47(3):121-126.
Medication reconciliation is used when a patient moves from one level or location of care to another, to ensure they are receiving the appropriate medications. This retrospective study reviewed completed medication reconciliations of adult patients transferring from the intensive care unit to the ward. Nearly one in five had an error requiring physician changes to the order. Of those errors, 19% were high-alert medications, most notably low-molecular-weight heparin.
Goodwin G, Marra E, Ramdin C, et al. Am J Emerg Med. 2023;70:90-95.
When the US Supreme Court overturned Roe v. Wade, access to safe reproductive care was restricted even for patients with wanted or non-viable pregnancies. This study describes trends in early pregnancy-related emergency department visits prior to the court decision and how new restrictions have resulted in physician uncertainty and delays in care in states with abortion bans. The authors recommend physicians be mindful of Emergency Medical Treatment and Active Labor Act (EMTALA) when caring for pregnant individuals in the emergency department.
Mohamed MR, Mohile SG, Juba KM, et al. Cancer. 2023;129(7):1096-1104.
Polypharmacy in older adults increases the risk of potentially inappropriate medications (PIM) and potential drug-drug interactions (PDI). This secondary analysis of a national study of older adults with advanced cancer sought to identify associations between polypharmacy (eight or more medications), PIMs, and PDIs with adverse cancer treatment outcomes. Polypharmacy and PDIs were associated with increased risk of adverse treatment outcomes, but PIMs were not.
Pradeda AM, Pérez MSA, Oliveira CF, et al. Farm Hosp. 2023;47(3):121-126.
Medication reconciliation is used when a patient moves from one level or location of care to another, to ensure they are receiving the appropriate medications. This retrospective study reviewed completed medication reconciliations of adult patients transferring from the intensive care unit to the ward. Nearly one in five had an error requiring physician changes to the order. Of those errors, 19% were high-alert medications, most notably low-molecular-weight heparin.
Zahl-Holmstad B, Garcia BH, Johnsgård T, et al. BMJ Open Qual. 2023;12(2):e002239.
Designated emergency department (ED) pharmacists are increasingly used to improve the quality of medication administration in the ED. This qualitative study explored patient perceptions of medication safety before and during an ED pharmacist-led intervention (including medication reconciliation and medication review) in collaboration with ED physicians. Participants underscored the importance of trust and responsibility but noted that it was not important who carried out these medication-related tasks, but rather that the participant received the help they needed.
Dadich A, Rodrigues J, De Bellis A, et al. Dementia (London). 2023;22(5):1057-1076.
Safety II involves studying what goes right in patient care instead of what went wrong. Using a video reflexive ethnography method and a Safety II approach, researchers analyzed the ways in which staff provided safe care in a specialized dementia ward. Identified themes included negotiating risk and balancing personhood vs. protocols.
Ames SG, Delaney RK, Houtrow AJ, et al. Pediatrics. 2023;152(1):e2022060975.
People with disabilities encounter a variety of system- and clinician-level barriers when seeking healthcare. This study reports on disability-based discrimination faced by children with medical complexities and their caregivers. Apathy, clinician assumptions, and lack of clinician knowledge were identified as drivers of discrimination resulting in limited accessibility, substandard care, and dehumanization.
Aiken LH, Lasater KB, Sloane DM, et al. JAMA Health Forum. 2023;4(7):e231809.
While the association between clinician burnout and patient safety are not new, the COVID-19 pandemic brought this safety concern back to the forefront. In this study conducted at 60 US Magnet hospitals, nurses and physicians reported high levels of burnout and rated their hospital unfavorably on patient safety. Increased nurse staffing was the top recommendation to reduce burnout with less emphasis on wellness and resilience programs.
Vickers-Smith R, Justice AC, Becker WC, et al. Am J Psych. 2023;180(6):426-436.
Racial and ethnic biases can affect diagnosis and negatively impact patient safety. Based on a sample of over 700,000 veterans, this study found that Black and Hispanic individuals consumed similar amounts of alcohol to White individuals but were more likely to be diagnosed with alcohol use disorder (AUD).
Schwappach DLB, Pfeiffer Y. Patient Saf Surg. 2023;17(1):15.
Retained surgical items (RSIs) can lead to serious patient harm. Survey findings from 21 clinicians and stakeholders in Switzerland emphasized the importance of addressing production pressures, encouraging a culture of safety and teamwork, and implementation of effective counting procedures to reduce the incidence of retained surgical items.
Rubisch HPK, Blaschke A-L, Berberat PO, et al. Adv Health Sci Educ Theory Pract. 2023;28(5):1523-1556.
Recognizing and learning from mistakes is a core component of medical and nursing education. Based on video recordings of bedside teaching lessons, this study explored how instructors react to and address student mistakes during bedside teaching lessons. Findings highlight the importance of giving purposeful feedback and allowing students the opportunity to recognize and correct their mistakes.
Kulkarni PA, Singh H. JAMA. 2023;330(4):317-318.
Artificial intelligence (AI) is an emerging technology to potentially improve care timeliness and diagnostic accuracy. This commentary provides a grounded assessment of this potential by examining clinician knowledge, physician examination skills, and health record data factors that affect the effect of AI chatbots as a tool driving diagnostic safety.
Starmer AJ, Michael MM, Spector ND, et al. Jt Comm J Qual Patient Saf. 2023;49(8):384-393.
Multiple handoffs during perioperative care present opportunities for error. This article outlines a conceptual framework to support the development, implementation, and evaluation of patient-centered handoffs during perioperative care. The authors describe a multi-component handoff improvement bundle including mnemonics and checklists (such as I-PASS), technology solutions to reinforce verbal handoffs, interprofessional handoff training and assessment, and leadership support to promote safety culture.
Ellis LA, Falkland E, Hibbert P, et al. Front Public Health. 2023;11:1217542.
Safety culture is recognized as an essential component of reducing or preventing errors and improving overall patient safety. This commentary calls for greater consistency in defining and measuring safety culture across settings. The authors describe challenges faced by patient safety professionals and researchers, and offer recommendations on overcoming them.
Card AJ. J Patient Saf. 2023;19(6):394-395.
A full cycle of examination, planning, and strategic implementation is required to improve safety through system change. This commentary explores reasons for the persistent overemphasis on patient safety incident tabulation and analysis in lieu of the employment of actions that serve to reduce the potential for accident occurrence.
Rosa R, Sposato K, Abbo LM. AORN J. 2023;117(5):300-311.
Preventing surgical site infections remains a persistent challenge to patient safety. This article outlines strategies to prevent surgical site infections during the perioperative period and the roles that infection surveillance, infection prevention bundles, and a culture of safety play a substantial role in decreasing the rate of surgical site infections.
Mahomedradja RF, Schinkel M, Sigaloff KCE, et al. Br J Clin Pharmacol. 2023;89(6):1724-1735.
Despite extensive research and interventions, medication prescribing errors in hospital continue to occur. This review sought to identify prescribing errors and factors that facilitate or prevent prescribing errors. Prescribing errors were categorized as prescriber-, prescription-, technology-, or organization-related, or unclassified. Most errors were organization-related. The authors recommend examining facilitators and barriers to prescribing safety prior to implementing new interventions.
Sahay A, McKenna L. Nurs Outlook. 2023;71(4):101992.
Clinicians and trainees experiencing psychological or emotional distress after adverse events are often referred to as “second victims.” This scoping review found that majority of the literature on nurses and nursing students as second victims focuses on psychological distress and symptomology, coping responses, and support-seeking behaviors. The authors discuss support strategies for second victims and the role of nursing leadership in supporting the well-being and mental health of nurses, such as peer-support programs and assessing workload allocation.
No results.
Maxwell A. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2023. Report no. OEI-06-21-00031.
Trigger tools are a strategy for identifying and classifying patient injuries associated with care. This toolkit provides guidance for problem exploration on 29 specific clinical conditions. The document is designed to assist teams in the review of medical record data resources that can elucidate preventability and identify harm. This toolkit provides an 18-element trigger tool oriented to hospitals with worksheets to translate its use to a variety of care environments.
Manchester, UK: Parliamentary and Health Service Ombudsman; June 2023. ISBN: 9781528642446.
Lack of accountability for systemic contributions to failure degrades efforts to generate improvement. This report discusses gaps in the British National Health Service patient safety culture. It calls for governmental oversight and commitment as the central activation lever necessary to achieve collective, coordinated effort and motivate large-scale action to support lasting change.
Newspaper/Magazine Article
Renault M. Stat. July 7, 2023.
Emergency vehicle transport can be dangerous for the patient, the clinician team, and the community. This article discusses the effect of ambulance use of alarm sirens on the safety of the service. Impacts such as psychological health of the patient and access to care units, should a crash occur, are discussed.
Course Material/Curriculum
Rockville, MD: Agency for Healthcare Research and Quality; July 2023.
The TeamSTEPPS® program was developed to support effective communication and teamwork in health care. The curriculum offers training for participants to implement TeamSTEPPS® in their organizations. The 3.0 version of the material has an increased focus on patient engagement and a broader range of clinical, administrative and leadership roles. The course includes updated evidence reviews, trainer guidance, measurement tools, a pocket guide quick reference to keyTeamSTEPPS® concepts and tools, and new patient videos.
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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