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August 16, 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. Intensive Crit Care Nurs. 2023;78:103480.
Safety culture, nurses' safety attitudes, and staffing ratios have been shown to impact fall rates and other healthcare associated events. This study assessed if healthcare-associated infections (HAIs) could be associated with nurses' safety attitudes and other quality and safety metrics in the intensive care unit (ICU). Increased job satisfaction was associated with lower rates of HAI, as were lower rates of missed care. The study also found nurses' perceptions and actual incidence of two HAI were positively correlated, suggesting nurses can provide valuable information on HAIs and HAI reduction efforts.
Hibbert PD, Molloy CJ, Schultz TJ, et al. Int J Qual Health Care. 2023;35(3):mzad056.
Accurate and reliable detection and measurement of adverse events remains challenging. This systematic review examined the difference in adverse events detected using the Global Trigger Tool compared to those detected via incident reporting systems. In 12 of the 14 included studies, less than 10% of adverse events detected using the Global Trigger Tool were also found in corresponding incident reporting systems. The authors of the review emphasize the importance of using multiple approaches and sources of patient safety data to enhance adverse event detection.
Weaver MD, Sullivan JP, Landrigan CP, et al. Jt Comm J Qual Patient Saf. 2023;49(11):634-647.
The Accreditation Council for Graduate Medical Education (ACGME) restrictions on resident work hours have improved resident well-being, but the impact on education, clinical and patient safety outcomes is less clear. This meta-analysis found that the 2003 ACGME restrictions (limiting residents to 80-hour work weeks and 28-hour shifts) was associated with an 11% reduction in mortality; however, there was no significant difference in mortality after the 2011 restrictions (limiting first-year residents to 16-hour shifts). These findings reinforce the impact of extended resident physician work hours and patient morbidity and mortality. The authors also recommend that future research examine the relationship between work hours and patient outcomes among other health care workers.
Ring LM, Cinotti J, Hom LA, et al. Pediatr Qual Saf. 2023;8(4):e671.
Previous research has identified gaps in medication reconciliation practices among hospitalized children. This quality improvement found that increased utilization of a patient-friendly discharge medication platform integrated into the electronic health record (EHR) system was associated with improved inpatient discharge medication reconciliation in pediatric acute care patients.
Alanazi FK, Lapkin S, Molloy L, et al. Intensive Crit Care Nurs. 2023;78:103480.
Safety culture, nurses' safety attitudes, and staffing ratios have been shown to impact fall rates and other healthcare associated events. This study assessed if healthcare-associated infections (HAIs) could be associated with nurses' safety attitudes and other quality and safety metrics in the intensive care unit (ICU). Increased job satisfaction was associated with lower rates of HAI, as were lower rates of missed care. The study also found nurses' perceptions and actual incidence of two HAI were positively correlated, suggesting nurses can provide valuable information on HAIs and HAI reduction efforts.
Barlow M, Morse KJ, Watson B, et al. Adv Simul (Lond). 2023;8(1):17.
Patient safety is improved when all members of the care team feel empowered to speak up about concerns. Equally important is the way the receiver understands and responds to the concern. Through an interprofessional simulation, this study assessed barriers and enablers of receiving a safety concern expressed by a junior nurse, either abruptly or politely and respectfully. Barriers and enablers to receiving the message were about equal no matter the way the concern was expressed, suggesting trainings that focus on speaking up should also focus on receiving those messages.
Dunbar EG, Massey AC, Lee YL, et al. Am Surg. 2023;89(7):3272-3274.
Medication reconciliation is an important care process anytime a patient transitions from one care setting to another, including emergency department to hospital admission. This study sought to determine the incidence of completed medication reconciliation for admitted trauma patients and the number of identified discrepancies. Of the 89 patients included in the study, more than a quarter did not receive an admission medication reconciliation (AMR), and of those with an AMR, 48% had at least one unintended discrepancy, indicating the importance of completing medication reconciliation for all admitted trauma patients.
Lyren A, Haines E, Fanta M, et al. BMJ Qual Saf. 2024;33(2):86-97.
Previous research has found that racial and ethnic disparities can hinder the safe care of pediatric patients. In this cross-sectional study, researchers examined racial and ethnic disparities in central line-associated bloodstream infection (CLABSI) and unplanned extubation (UE) rates across 27 children’s hospitals in the United States. Compared to White patients, Black and African-American patients had higher UE rates and Hispanic, Native American, and Pacific Islander patients had higher CLABSI rates.
Shepherd L, Chilton S, Cristancho SM. Acad Med. 2023;98(8):934-940.
Learning from mistakes is an important component of medical education. In this study, medical residents at one large Canadian hospital participated in semi-structured interviews exploring how residents experience and learn from medical errors. Residents described learning to differentiate errors from complications, how the work environment and workload creates vulnerabilities, approaches to manage errors, and identifying avenues for support in order to move past an error.
McMullen S, Panagioti M, Planner C, et al. Health Expect. 2023;26(5):2064-2074.
Caregivers and family members offer a unique perspective on patient safety. In this study, patient and caregiver stakeholders outlined the safety threats affecting patients discharged from mental health services and the well-being of caregivers as well as potential solutions. Participants highlighted approaches to improve caregiver involvement, patient and caregiver wellness and education, and the policy and system environments.
Engstrom T, McCourt E, Canning M, et al. NPJ Digit Med. 2023;6(1):133.
Computerized provider order entry (CPOE), clinical decision support (CDS), and other technologies can reduce prescribing errors, but their initial implementation may present new errors. This study reports prescribing errors before and after transition to digital hospital records. Results show significant decreases in prescribing errors after transition, but also identified new problems, such as alert fatigue, that needed additional attention to remediate.
Zińczuk A, Rorat M, Simon K, et al. Viruses. 2023;15(7):1430.
The COVID-19 pandemic exacerbated many existing patient safety challenges. This retrospective analysis of 477 fatal COVID-19 cases at one hospital in Poland found that one-third of patients experienced a healthcare-acquired infection during their hospitalization as well as other hospital-acquired complications, including thrombolytic and/or bleeding complications, acute kidney injury, and exacerbation of chronic heart disease. The analysis also found that many patients experienced delays in specialist treatment (33%) or lack of specialist treatment (17%) during their hospitalization.
Bittencourt NCC de M, Duarte S da CM, Marcon SS, et al. Healthcare (Basel). 2023;11(14):2030.
Adverse events in palliative care can include inappropriate pain management, preventable hospital (re)admissions, falls, and pressure injuries. This paper outlines ways palliative care is not always received timely, the uniqueness of patient safety within palliative care, and how to raise awareness of both of these issues for healthcare providers, educators, and patients and families.
Hung A, Wang J, Moriarty F, et al. J Am Geriatr Soc. 2023;71(6):2023-2027.
Deprescribing is used to reduce the risk of adverse drug events resulting from polypharmacy among older adults. This article outlines several recommendations for improved cost-effectiveness analyses of deprescribing interventions to support decision makers.
Cleary E, Bloomfield J, Frotjold A, et al. J Interprof Care. 2024;38(2):346-376.
Schools of health are increasingly developing interprofessional courses on patient safety. This realist synthesis of the literature presents the contexts in which interprofessional education (IPE) does or does not improve students' attitudes towards patient safety, the methods of teaching and learning, and identifiable and potential outcomes.
Duhalde H, Bjuresäter K, Karlsson I, et al. Int Emerg Nurs. 2023;69:101296.
Missed nursing care (MNC) refers to needed nursing care that is delayed, partially completed, or not completed at all, and can result in adverse events. This systematic review summarizes missed nursing care in emergency departments (ED). Causes of MNC include overcrowding and patients with complex care needs, which may result in medication errors, pressure injuries, or patient deterioration.
Weaver MD, Sullivan JP, Landrigan CP, et al. Jt Comm J Qual Patient Saf. 2023;49(11):634-647.
The Accreditation Council for Graduate Medical Education (ACGME) restrictions on resident work hours have improved resident well-being, but the impact on education, clinical and patient safety outcomes is less clear. This meta-analysis found that the 2003 ACGME restrictions (limiting residents to 80-hour work weeks and 28-hour shifts) was associated with an 11% reduction in mortality; however, there was no significant difference in mortality after the 2011 restrictions (limiting first-year residents to 16-hour shifts). These findings reinforce the impact of extended resident physician work hours and patient morbidity and mortality. The authors also recommend that future research examine the relationship between work hours and patient outcomes among other health care workers.
No results.
Newspaper/Magazine Article
Kwon S. KFF Health News. August 8, 2023
Implicit bias and systemic racism are known to affect the safety of Black maternal care. This story describes an incident of maternal death and the family’s effort to demonstrate the role of discrimination in the outcome and hold the clinicians and organization involved responsible.
Rockville, MD: Agency for Research and Quality; July 27, 2023. Notice Number NOT-HS-23-018.
Diagnostic errors occur in all settings of care and are a primary challenge to safe health care. This announcement raises awareness of two upcoming funding opportunities for understanding and improving diagnostic safety in diverse ambulatory care environments. The funding will target the incidence and contributory factors of diagnostic error within the array of ambulatory care services and the development of strategies and interventions to improve diagnostic safety in ambulatory care.
Newspaper/Magazine Article
Mann B. Health Shots. National Public Radio. August 7, 2023.
Stigma against behavioral health conditions is known to affect the quality of care relationships and therapeutic actions. This news article discusses the limited use of methadone and other medications as strategies to assist in the care and recovery of opioid use disorder patients.
James C, Singh K, Valley TS, et al. Rockville, MD; Agency for Healthcare Research and Quality; July 2023. AHRQ Publication No. 23-0040-4-EF.
As artificial intelligence (AI) and machine learning (ML) become established in health care, it is critical for clinicians and patients to effectively collaborate to use AI safely. This Issue Brief adds to a series of diagnostic-focused reports and presents a framework to guide patients and clinicians on working as team members when using AI and ML to make diagnostic decisions.
Newspaper/Magazine Article
Salamon M. Harvard Women's Health Watch. August 1, 2023
Patients can help minimize the potential for adverse events while in the hospital. Actions such as working with a care partner, tracking medications, and recognizing fall risks can protect against mistakes causing harm.
Rockville, MD: Agency for Healthcare Research and Quality; July 2023.
Obstetric hemorrhage and severe high blood pressure during pregnancy are leading known causes of preventable maternal harms in the United States. The AHRQ Safety Program for Perinatal Care, Phase 2 developed toolkits consisting of case scenarios, slides, and facilitators guides to work in tandem to address these threats to maternal safety. The materials inform training opportunities to improve the safety culture of labor and delivery units and decrease maternal and neonatal adverse events that result from poor communication and system failures.
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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