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August 9, 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
Chen Z, Gleason LJ, Konetzka RT, et al. Health Serv Res. 2023;58:1109-1118.
Researchers and patient advocates have raised concerns about the accuracy of self-reported data on Care Compare, the Medicare and Medicaid website that publicly reports facility-level quality and safety measures of certified facilities, including nursing homes. This study used hospital claims to determine the percentage of nursing home residents admitted to a hospital for a urinary tract infection (UTI) and compared that number to rates reported on Care Compare. The results show only 79% of claims-based UTIs were reported by the facility. Reporting rates for Black residents or nursing homes with a higher percentage of Black residents were even lower.
Hogerwaard M, Stolk M, Dijk L van, et al. BMJ Open Qual. 2023;12:e002023.
Barcode medication administration (BCMA) technology is a useful tool to reduce medication administration errors (MAE) in the operating room. This study used a pre-post design to estimate the rate of MAE before and after BCMA implementation on infusion pumps. MAE were significantly reduced and up to 90% of errors were considered preventable, if the staff had utilized BCMA. Reasons for not using BCMA included unreadable barcodes, lack of time, and resistance to new processes.
Rosen M, Dy SM, Stewart CM, et al. Making Healthcare Safer IV Series. Rockville, MD: Agency for Healthcare Research and Quality; July 2023. AHRQ Publication no. 23-EHC019-1.
Reducing preventable harm in healthcare settings remains a national priority. This report summarizes the results of the prioritization process used to identify patient safety practices meriting inclusion in the fourth installment of the Making Healthcare Safer (MHS) series (previous installments were published in 2001, 2013, and 2020). The fifteen-member Technical Expert Panel identified 27 priority patient safety practices for examination in the forthcoming report, including several practices that have not been covered in previous MHS reports (e.g., family/caregiver engagement, preventing non-ventilator associated pneumonia, supply chain disruption, high reliability, post-event communication programs).
Chen Z, Gleason LJ, Konetzka RT, et al. Health Serv Res. 2023;58:1109-1118.
Researchers and patient advocates have raised concerns about the accuracy of self-reported data on Care Compare, the Medicare and Medicaid website that publicly reports facility-level quality and safety measures of certified facilities, including nursing homes. This study used hospital claims to determine the percentage of nursing home residents admitted to a hospital for a urinary tract infection (UTI) and compared that number to rates reported on Care Compare. The results show only 79% of claims-based UTIs were reported by the facility. Reporting rates for Black residents or nursing homes with a higher percentage of Black residents were even lower.
Osborne TF, Veigulis ZP, Arreola DM, et al. Digit Health. 2023;9:20552076231187727.
Preventing patient falls in hospital settings is a patient safety priority. Set at one Veterans Health Administration (VHA) hospital, this study found that use of SmartSocks – socks containing pressure sensors that detect when a patient is trying to stand up – reduced falls by more than 50% among patients determined to be at high-risk of falling.
Green MA, McKee M, Hamilton OKL, et al. BMJ. 2023;328:e075133.
Many patients were unable to access care during the pandemic, particularly during surges. This longitudinal cohort study in the UK reports that 35% of participants reported disrupted access to care (e.g., cancelled or postponed appointments or procedures). While overall rates of potentially preventable hospitalization were low (3%), those who reported disrupted access had increased risk of potentially preventable hospitalization.
Centola D, Becker J, Zhang J, et al. Proc Natl Acad Sci U S A. 2023;120:e2108290120.
Collective intelligence posits that the judgment (in this case, diagnostic accuracy) of a group of individuals outperforms the judgment of a single individual. This study sought to determine if real-time information-sharing improved not only group diagnostic accuracy, but also diagnostic accuracy of the individuals within the group. Individual accuracy did improve, suggesting real-time information-sharing between physicians could improve diagnostic decision-making in practice, although additional research is required.
Monkman H, Kuziemsky C, Homco J, et al. Stud Health Technol Inform. 2023;304:39-43.
Implementation challenges can hinder the safety of telehealth. In this study, medical students used Healthcare Failure Modes and Effect Analysis to identify the causes of failures in telehealth and potential prevention strategies. Four categories of failures were identified: technical issues, patient safety, communication, and social and structural determinants.
Hogerwaard M, Stolk M, Dijk L van, et al. BMJ Open Qual. 2023;12:e002023.
Barcode medication administration (BCMA) technology is a useful tool to reduce medication administration errors (MAE) in the operating room. This study used a pre-post design to estimate the rate of MAE before and after BCMA implementation on infusion pumps. MAE were significantly reduced and up to 90% of errors were considered preventable, if the staff had utilized BCMA. Reasons for not using BCMA included unreadable barcodes, lack of time, and resistance to new processes.
Powis M, Dara C, Macedo A, et al. BMJ Open Quality. 2023;12:e002211.
Medication reconciliation can help providers identify potential safety issues during medication administration. Based on interviews with stakeholders, this study examined medication reconciliation practices across Canadian cancer centers. Although a high proportion of the centers had a process for collecting best possible medication history (BPMH, 81%), implementation of a complete medication reconciliation process was uncommon. Stakeholders identified several barriers to implementation, including lack of resources and a lack of electronic health record interoperability across institutions, systems, and community pharmacies.
Kamta J, Fregoso B, Lee A, et al. Prehosp Emerg Care. 2024;28:506-512.
Handoffs from emergency medical services (EMS) to the emergency department (ED) are vulnerable to communication errors due to the time-pressured environment. This study reports on the implementation of an electronic health record (EHR) tool that added pre-hospital medication administration to the ED triage note to reduce medication administration errors (MAE). Although most ED providers reported they "always" review the triage note, MAE rates did not improve following implementation.
Alfred MC, Wilson D, DeForest E, et al. Jt Comm J Qual Patient Saf. 2024;50:6-15.
In the United States, women and birthing people of color experience disproportionately high rates of mortality and severe maternal morbidity (SMM). Researchers analyzed two years of incident reports (IR) to ascertain potential system issues contributing to SMM and racial/ethnic disparities at one hospital. Non-Hispanic Black individuals were over-represented in IRs, but there were no statistically significant differences in harm level.
Kieren MQ, Kelly MM, Garcia MA, et al. Acad Pediatr. 2023;23:1535-1541.
Parents of children with medical complexity are an important part of the care team and can raise awareness of safety concerns. This study included parents of children with medical complexity who had reported safety concerns to members of their child's healthcare team. Parents whose concerns were validated and addressed felt increased trust in the team and hospital, whereas those whose concerns were invalidated or ignored felt disrespected and judged.
Rotteau L, Othman D, Dunbar-Yaffe R, et al. BMJ Qual Saf. 2024;33:33-42.
Safety huddles are increasingly used to encourage team communication about safety threats and learning from mistakes. This qualitative study with huddle leaders and participants at five sites found that huddles can enhance engagement in patient safety and identify opportunities for increased support from organizational leadership.
Schwappach DLB, Ratwani RM. J Patient Saf. 2023;19:38-39.
Usability concerns continue to affect the safe use of electronic health information systems. This commentary describes the role of vendors in improving usability, how regular testing can ensure safety, and the impact of organizational culture on the safe use of information technology over time.
Abid MH. J Clin Outcomes Manag. 2023;30:67-70.
Despite extensive research and education, diagnostic errors continue to be a global health concern. This article encourages a comprehensive strategy combining human (patient) experience and artificial intelligence (AI) to create a safer, more patient-focused health system, specifically concerning diagnostic safety. Key to this strategy is open communication between patients and providers, patient involvement in AI development, and reduction of bias in AI systems.
Morris J, Schomerus G. Drug Alcohol Rev. 2023;42:1264-1268.
Stigma and bias in healthcare undermine patient safety. This article discusses how stigma associated with alcohol use can impede the delivery of quality health care and contribute to poor patient outcomes.
Péculo‐Carrasco J‐A, Luque‐Hernández MJ, Rodríguez‐Ruiz H‐J, et al. J Clin Nurs. 2023;32:4473-4491.
Emergency medical services (EMS) and pre-hospital care present unique challenges to ensure the delivery of safe care. This systematic review, including both qualitative and quantitative studies, identified four dimensions influencing patient perceptions of safety in pre-hospital care – satisfactory response from the emergency medical system, competence of EMS personnel, the setting of care/environmental factors, and patients’ personal characteristics.
Organizational Policy/Guidelines
Bijok B, Jaulin F, Picard J, et al. Anaesth Crit Care Pain Med. 2023;42:101262.
Human factors influence how humans and systems interact to make processes more reliable or more error-prone during both normal and unexpected circumstances. This guideline provides recommendations centered on elements of communication, the organization, the work environment, and training to guide the consideration of human factors in improvement actions during critical anesthesia or intensive care situations.
Li CJ, Shah YB, Harness ED, et al. Am J Med Qual. 2023;38:196-202.
Burnout among healthcare workers is a public health concern. This systematic review explores the link between physician burnout and medical errors, the influence of physician demographics (e.g., specialty, level of training) and the financial impact of physician burnout.
No results.
Rosen M, Dy SM, Stewart CM, et al. Making Healthcare Safer IV Series. Rockville, MD: Agency for Healthcare Research and Quality; July 2023. AHRQ Publication no. 23-EHC019-1.
Reducing preventable harm in healthcare settings remains a national priority. This report summarizes the results of the prioritization process used to identify patient safety practices meriting inclusion in the fourth installment of the Making Healthcare Safer (MHS) series (previous installments were published in 2001, 2013, and 2020). The fifteen-member Technical Expert Panel identified 27 priority patient safety practices for examination in the forthcoming report, including several practices that have not been covered in previous MHS reports (e.g., family/caregiver engagement, preventing non-ventilator associated pneumonia, supply chain disruption, high reliability, post-event communication programs).
Rockville, MD: Agency for Healthcare Research and Quality: July 2023 - May 2024.
Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of examinations on family caregiver engagement and clinician fatigue are now available.
ISMP Medication Safety Alert! Acute care edition. July 13, 2023;(4):1-3;July 27, 2023;(5):1-5.
Risk Evaluation and Mitigation Strategy (REMS) programs help to ensure the safe use of distinct medications through communication, patient information, and implementation support. Part I of this article series examines systemic barriers to the deployment of REMS as a strategy to decrease potential for drug-related harm and medication error. Part II looks at the processes that one health system used to implement REMS.
Audiovisual
Burton S. New York Times and Serial Productions. June 30-July 27, 2023.
Unnoticed drug diversion can result in harm to patients, clinicians, and organizations. This series describes how diversion contributed to unnecessary pain in fertility clinic patients. The problem was compounded by a lack of attention to women voicing their concerns about procedural pain.
Newspaper/Magazine Article
Jaklevic MC. HealthJournalism.org. July 27, 2023.
Published rates of medical errors continue to draw attention to gaps in care that demonstrate the need for continued effort toward development and implementation of system-focused safety solutions. This article discusses the importance of representing error statistics responsibly and offers recommendations to ensure accurate representations of the challenges facing safe care delivery.
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
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.
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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