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August 2, 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

Johnson EA, Dudding KM, Carrington JM. Nurs Inq. 2024;31:e12583.
Research on artificial intelligence (AI) in medicine is rapidly increasing including AI in nursing care. In this commentary, the authors describe the challenges of using AI in healthcare and the unique implications for nursing practice and policy. In particular, nurses should be involved in the development and testing of any AI used in the nursing process.
Walsh DJ, Sahm LJ, O'Driscoll M, et al. J Geriatr Oncol. 2023;14:101540.
Older adults with cancer are typically prescribed multiple medications (i.e., polypharmacy) and are therefore at risk of adverse drug events (ADE). In this study, the medical records of older adults (those at least 70 years old) receiving cancer care who had an unplanned hospital admission were reviewed to determine if it was potentially related to an ADE. Of the hospitalized patients, more than half were potentially due to ADE at three and six months after the initial oncology visit. Including a clinical pharmacist may help reduce ADEs and hospitalizations.
Wang Y, Eldridge N, Metersky ML, et al. Circ Cardiovasc Qual Outcomes. 2023;16:e009573.
Unplanned hospital readmission and 30-day all-cause mortality rates are indicators of hospital safety. This study analyzed the association of these two indicators with in-hospital adverse events (AE) for patients admitted with heart failure. Results suggest patients with heart failure admitted to hospitals with high rates of 30-day all-cause mortality and readmission are at increased risk for in-hospital AE. The authors describe several possible explanations for these findings.
Maras SA. Soc Sci Med. 2023;331:116066.
Intimate partner violence (IPV) victims and survivors frequently access healthcare, but don’t always receive trauma-informed care or referrals to IPV resources. This study asked IPV survivors what patient safety meant to them. They described it as care that contained: 1) compassionate and/or trauma-informed care; 2) physically safe spaces; and/or 3) a connection to social resources. Survivors described ways healthcare providers could improve IPV safety.
Joshi RN, Kalaminsky S, Feemster A-A, et al. Jt Comm J Qual Patient Saf. 2023;49:599-603.
Technology, such as barcode scanning, is a recognized method for improving medication safety, but poor design may lead to alert fatigue. This article describes a quality improvement project to reduce barcode-assisted medication preparation alerts in the hospital's pharmacies. More than 40% of alerts were identified as "barcode not recognized," such as packages containing more than one barcode. Problems associated with the highest volume of alerts were resolved with staff education, workflow changes, and changes.
Rabbani N, Pageler NM, Hoffman JM, et al. Appl Clin Inform. 2023;14:521-527.
Implementation of or upgrades to new electronic health records (EHR) is a complex process which sometimes results in unforeseen negative consequences. This study examines hospital-acquired conditions (HACs) and care bundle compliance rates at 27 pediatric hospitals before, during, and after implementation or upgrade of EHR systems. Contrary to previous studies, no significant differences were found in either HAC or bundle compliance rates.
Falcone ML, Tokac U, Fish AF, et al. J Patient Saf. 2023;19:323-330.
AHRQ's Hospital Survey on Patient Safety Culture (SOPS) is widely used to measure hospital staff's opinion on safety culture in their organization. Exploratory factor analysis was conducted with SOPS data to compare with the six components of Patient Safety Culture Theoretical Framework. Construct validity was good, but the authors recommend creating a supplemental survey on deference to expertise and resilience.
Abramovich I, Matias B, Norte G, et al. Eur J Anaesthesiol. 2023;40:587-595.
Fatigue and sleep deprivation of anesthesia providers can result in decreased non-technical skills and psychomotor functioning. This study of 1,200 anesthesia and intensive care trainees in Europe describes the impact of work-related fatigue on well-being, commuting, and potential for medical errors. Two-thirds of respondents reported making or nearly making a medical error after working long hours. In addition to implementing shorter work schedules, the authors also encourage a culture where it is acceptable to admit fatigue, and where resting is encouraged.
Walsh DJ, Sahm LJ, O'Driscoll M, et al. J Geriatr Oncol. 2023;14:101540.
Older adults with cancer are typically prescribed multiple medications (i.e., polypharmacy) and are therefore at risk of adverse drug events (ADE). In this study, the medical records of older adults (those at least 70 years old) receiving cancer care who had an unplanned hospital admission were reviewed to determine if it was potentially related to an ADE. Of the hospitalized patients, more than half were potentially due to ADE at three and six months after the initial oncology visit. Including a clinical pharmacist may help reduce ADEs and hospitalizations.
Estock JL, Codario RA, Keddem S, et al. Diabetes Technol Ther. 2023;25:343-355.
Insulin pump malfunctions are a known contributor to adverse events. This study used six months of adverse events reported to the Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database to identify root causes and consequences of errors associated with insulin pump malfunctions. Hyper- and hypoglycemia were the most common clinical consequences of the malfunction; only half of the reports identified a potential root cause.
Goldman J, Rotteau L, Flintoft V, et al. BMJ Qual Saf. 2023;32:470-478.
Learning collaboratives within the Canadian Patient Safety Institute are working to implement the Measurement and Monitoring of Safety Framework (MMSF). This paper describes the collaboratives’ experiences with integrating MMSF into their organizations. Hospitals reported small scale success and described challenges with implementation when the Framework was not aligned with existing quality and safety processes.
Wang Y, Eldridge N, Metersky ML, et al. Circ Cardiovasc Qual Outcomes. 2023;16:e009573.
Unplanned hospital readmission and 30-day all-cause mortality rates are indicators of hospital safety. This study analyzed the association of these two indicators with in-hospital adverse events (AE) for patients admitted with heart failure. Results suggest patients with heart failure admitted to hospitals with high rates of 30-day all-cause mortality and readmission are at increased risk for in-hospital AE. The authors describe several possible explanations for these findings.
Sha S, Aleshire M. Health Promot Pract. 2023;24:536-545.
Regular depression screening is recommended for all adults. Using a clinical vignette, the sexuality Implicit Association Test (IAT), and measures of explicit bias, this study examined the relationship of primary care providers' (PCP) bias towards lesbian women and recommendations for depression screening. Providers who recommended screening showed slightly more positive explicit attitudes and slightly lower, though not statistically significant, implicit bias towards lesbian women. However, recommendation rates among all providers were low, at only 38%.
Nosanov L, Elseth AJ, Maxwell J, et al. Am J Surg. 2023;226:726-728.
The second victim concept encompasses an important concern for the impact of unsafe care on health care workers. This commentary discusses the topic and the need for system-level solutions to ensure surgical team members involved with patient harm due to errors can heal, and in doing so, provide safe care to their patients.
Johnson EA, Dudding KM, Carrington JM. Nurs Inq. 2024;31:e12583.
Research on artificial intelligence (AI) in medicine is rapidly increasing including AI in nursing care. In this commentary, the authors describe the challenges of using AI in healthcare and the unique implications for nursing practice and policy. In particular, nurses should be involved in the development and testing of any AI used in the nursing process.
Guppy JH, Widlund H, Munro R, et al. BMJ Lead. 2024;8:83-87.
Incivility hinders clinical performance, increases errors, and negatively impacts safety culture. This review examines recent literature on the effects of incivility in healthcare and strategies to address it. The article proposes ways to implement those strategies, with an emphasis on the UK National Health Service. The authors conclude that tackling incivility begins with highlighting the issue organizationally, regionally, and nationally; ensuring robust reporting and recognition strategies; and, devising mechanisms to confront incivility.
Alemu W, Cimiotti JP. J Healthc Qual. 2023;45:233-241.
Medication administration is a complex process and prone to errors. This review was conducted to identify predictors and incidence of medication administration errors (MAE) in African hospitals. Most predictors were at the system level (e.g., work environment, interruptions), followed by patient and professional/provider factors. As the number of included studies was low (13 studies) and most came from one nation, additional studies are needed.
Shaw L, Lawal HM, Briscoe S, et al. Health Expect. 2023;26:2127-2150.
Patients who experience life-changing adverse events due to errors, and their families, typically want disclosure of the error and appropriate accountability. This systematic review identified 41 studies exploring the views of those affected by adverse events. Four themes were identified: transparency, person-centeredness, trustworthiness, and restorative justice. Applying these themes to investigations may result in ensuring the process and outcomes are experienced as "fair" to those impacted.
Hilario C, Louie-Poon S, Taylor M, et al. Int J Soc Determinants Health Health Serv. 2023;53:343-353.
Structural racism is increasingly recognized as a social determinant of health. This systematic review identified 13 articles on the impact of racism on racialized adolescents. Most articles focused on the impact of racism on healthcare access and utilization, and in general or mental health care. Research into multiple forms of racism (i.e., institutional, interpersonal, internalized) and development and incorporation of robust measures of racism is needed to advance the field.
No results.

Washington DC: Department of Veterans Affairs, Office of Inspector General; June 29, 2023. Report no. 22-01540-146.

This report analyzed a patient suicide at an emergency department and determined factors in the delay of care that contributed to patient harm. This report shares recommendations to address leadership failures and other deficiencies including poor screening and patient monitoring. Post-event gaps identified include poor root cause analysis, disclosure, and reporting activities.

Simmons-Duffin S. Health Shots. National Public Radio. July 20, 2023.

The range of unintended consequences stemming from abortion restrictions are beginning to be documented. This news story highlights three incidents of physical and psychological patient harm resulting from lack of access to needed care during pregnancy.

London, UK: NHS England; July 2023.

A strong patient safety culture needs nurturing to serve as a foundation for launching and sustaining improvements. This toolkit provides access to existing tools that support teamwork and communication, fairness, psychological safety, promotion of diversity and inclusivity, and civility as elements of a safety culture.

Agency for Healthcare Research and Quality, Rockville, MD. July 2023.

Engaging patients to capture their insights after diagnostic error is one of the top patient safety strategies. This pair of issue briefs describes how organizations can use patient experience to inform improvements in diagnosis. Volume 1: Why Patient Narratives Matter highlights how patient perspectives offer unique information about the impacts of diagnosis-related events on patient care trajectories through the healthcare system. Volume 2: Eliciting Patient Narratives emphasizes that rigorous methods are needed to elicit patient experiences. Both briefs identify areas in which more research is needed about patients’ diagnostic experience.
Special or Theme Issue

Abraham J, Rosen M, Greilich PE eds. Jt Comm J Qual Patient Saf. 2023;49(8):341-434.

Handoffs occur several times during a surgical procedure, increasing the risk of communication mistakes and misunderstandings. This special issue explores perioperative handoffs and strategies to improve them. Topics covered include information accuracy, teamwork science, and artificial intelligence.

This Month’s WebM&Ms

WebM&M Cases
By Christian Bohringer, MBBS, and Ryan Osborne, MD |
This case describes a 27-year-old primigravid woman who requested neuraxial anesthesia during induction of labor. The anesthesia care provider, who was sleep deprived near the end of a 48-hour call shift (during which they only slept for 3 hours), performed the procedure successfully but injected an analgesic drug that was not appropriate for this indication. As a result, the patient suffered slower onset of analgesia and significant pruritis, and required more prolonged monitoring, than if she had received the correct medication. The commentary discusses the implications of sleep deprivation, especially in high-risk settings such as anesthesia care and obstetric care, and approaches to improve patient safety during labor and delivery.
WebM&M Cases
Spotlight Case
Sarah Marshall, MD and Nina M. Boe, MD |
A 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She was treated for dehydration and vomiting, but not aggressively enough, and her metabolic acidosis worsened over several days. The primary team hesitated to prescribe medications safe in pregnancy and delayed reaching out to the Maternal Fetal Medicine (MFM) consultant, who made recommendations but did not ensure that the primary team received and understood the information. The commentary highlights how breakdowns in communication amongst providers can lead to medical errors and prolonged hospitalization and how the principles of team-based care, communication, and a culture of safety can improve care in complex health care situations.
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.

This Month’s Perspectives

Kathleen Sanford
Interview
Kathleen Sanford DBA, RN, FAAN, FACHE; Sue Schuelke PhD, RN-BC, CNE, CCRN-K; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD |
Kathleen Sanford is the chief nursing officer and an executive vice president at CommonSpirit. Sue Schuelke is an assistant professor at the College of Nursing–Lincoln Division, University of Nebraska Medical Center. They have pioneered and tested a new model of nursing care that utilizes technology to add experienced expert nurses to care teams, called Virtual Nursing.
Patricia McGaffigan
Perspectives on Safety
Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD |
Patricia McGaffigan is the Vice President for Safety Programs at the Institute for Healthcare Improvement and President of the Certification Board for Professionals in Patient Safety. We spoke to Patricia about patient safety trends and how patient safety will move beyond the pandemic.
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