Email Updates
September 6, 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
Christensen SM, Andrews SR, Fox ER. Am J Health Syst Pharm. 2023;80 :S119-S122.
To maximize safety benefits of smart infusion pumps, drug libraries between the pump, electronic health record (EHR) and pharmacy must be standardized. This article describes the proactive standardization between drug libraries for continuous infusions, including medication names, concentrations, and pump rates. 82 updates were required across the three libraries.
Mohamoud YA, Cassidy E, Fuchs E, et al. MMWR Morb Mortal Wkly Rep. 2023;72:961–967.
Previous research has found that women often experience mistreatment and discrimination during maternity care. This CDC analysis of survey data for 2,402 respondents found that approximately one in five women experienced at least one type of mistreatment during maternity care (i.e., being ignored or refused, being shouted at or scolded, having their physical privacy violated). Nearly 29% of respondents reported experiencing at least one form of discrimination during their maternity care (i.e., age-, weight-, income-, or race/ethnicity-based discrimination).
Wells M, Henry B, Goldstein L. Prehosp Disaster Med. 2023;38:471-484.
Inaccurate estimations of patient weight can lead to medication errors in the prehospital period. This systematic review of 9 studies concluded that there is insufficient evidence to assess the accuracy of weight estimation approaches used in the EMS setting or by paramedics, underscoring the need for additional, robust research in this area.
Grubenhoff JA, Bakel LA, Dominguez F, et al. Jt Comm J Qual Patient Saf. 2023;49:547-557.
Clinical care pathways (CP) standardize care to ensure evidence-based practices are consistently followed. This study analyzed missed diagnostic opportunities (MDO) of pediatric musculoskeletal infections that could have been mitigated had the CP recommendations been adhered to. Misinterpretation of laboratory results was a critical contributor to MDO by both pediatric emergency providers and orthopedic consultants.
Christensen SM, Andrews SR, Fox ER. Am J Health Syst Pharm. 2023;80 :S119-S122.
To maximize safety benefits of smart infusion pumps, drug libraries between the pump, electronic health record (EHR) and pharmacy must be standardized. This article describes the proactive standardization between drug libraries for continuous infusions, including medication names, concentrations, and pump rates. 82 updates were required across the three libraries.
Mauskar S, Ngo T, Haskell H, et al. J Hosp Med. 2023;18:777-786.
Parents of children with medical complexity can offer unique perspectives on hospital quality and safety. Prior to their child's discharge, parents were surveyed about their child's care, medications, safety, and other concerns experienced during their stay. Parents reported experiencing miscommunication with the providers and providers seemingly not communicating with each other. They also reported inconsistency in care/care plans, unmet expectations, lack of transparency, and a desire for their expertise to be taken seriously.
Wiggett A, Fischer G. Arch Pathol Lab Med. 2023;147:933-939.
Miscommunication between pathologists and surgeons can lead to significant patient harm. This study identified multiple discrepancies between pathologist-listed diagnoses included in intraoperative consult notes compared to surgeon-dictated operative notes. Discrepancies were most common in multipart cases and those involving deferrals.
de Dios JG, Lopez-Pineda A, Juan GM-P, et al. BMC Pediatr. 2023;23:380.
Children are at-risk for medication errors in the home setting, but no single database exists to collect these errors. This study compared parent and pediatrician perspectives on home medication safety for children aged 14 and under. Approximately 80% of pediatricians thought parents consulted the internet for information about their child's care and medications, and an equal percent of parents reported consulting their healthcare provider. Both groups reported lack of parental knowledge as the main contributor to medication errors, and most pediatricians supported the idea of a mechanism for collecting parent-reported errors and a learning system to support family engagement in medication error prevention.
Lockery JE, Collyer TA, Woods RL, et al. J Am Geriatr Soc. 2023;71:2495-2505.
Potentially inappropriate medications (PIM) are a known contributor to patient harm in older adults. In contrast to most studies of PIM in patients with comorbid conditions or residing in hospitals or nursing homes, this study evaluated the impact of PIM use in community-dwelling older adults without significant disability. Participants with at least one PIM were at increased risk of physical disability and hospitalization over the study period (8 years) than those not taking any PIM. However, both groups had similar rates of death.
Ojeda IM, Sánchez-Cuervo M, Candela-Toha Á, et al. Crit Care Nurs. 2023;43:30-38.
High-alert medications can cause serious patient harm if administered incorrectly. This article describes a quality improvement project to reduce medication errors involving high-alert sedative and analgesic medications in the intensive care unit (ICU) through use of protocolized and centralized smart intravenous infusion pump technology. Use of the protocolized software led to the interception of nearly 400 infusion-related programming errors.
Garcia-Jorda D, Nikitovic D, Gilfoyle E. Simul Healthc. 2023;18:232-239.
Simulation trainings are widely used to identify safety threats and improve processes. By analyzing video recordings of pediatric cardiac arrest simulations, researchers were able to identify 5 main areas of errors: clinical, planning and execution, communication, distraction, and knowledge/training. Investigating the root causes of these errors can result in improved trainings and, thus, improved patient outcomes.
Mohamoud YA, Cassidy E, Fuchs E, et al. MMWR Morb Mortal Wkly Rep. 2023;72:961–967.
Previous research has found that women often experience mistreatment and discrimination during maternity care. This CDC analysis of survey data for 2,402 respondents found that approximately one in five women experienced at least one type of mistreatment during maternity care (i.e., being ignored or refused, being shouted at or scolded, having their physical privacy violated). Nearly 29% of respondents reported experiencing at least one form of discrimination during their maternity care (i.e., age-, weight-, income-, or race/ethnicity-based discrimination).
Ong N, Lucien A, Long JC, et al. BMJ Open. 2023;13:e071494.
Children with intellectual disabilities can be at higher risk for patient safety events. Based on semi-structured interviews and focus groups with healthcare professionals, this study describes several themes regarding healthcare professionals’ perspectives about patient safety considerations when caring for children and young people with intellectual disabilities. Findings underscore the importance of considering additional vulnerabilities, improving engagement with patients and families, and mitigating negative attitudes and biases.
Tan GM, Murto K, Downey LA, et al. Paediatr Anaesth. 2023;33:609-619.
Blood management errors can lead to serious patient harm. This article highlights five patient safety risks during pediatric perioperative blood management (failure to recognize and treat preoperative anemia, failure to obtain informed consent regarding perioperative blood management, failure to consider specific intraoperative blood conservation techniques in children, failure to recognize massive hemorrhage, failure to prevent unnecessary transfusion). The authors discuss potential solutions to address these safety risks.
McGurgan P. Aust N Z J Obstet Gynaecol. 2023;63:606-611.
Individual-, team-, and systems-based factors can affect safety during childbirth. This article discusses several patient safety threats that can hinder the safety of vaginal birth after cesarean (VAC) deliveries in high population density areas, including staffing and resource limitations, cultural and human factors, and patient communication.
AMA J Ethics. 2023;25:E615-E623.
The safety culture of an operating room is known to affect teamwork and patient outcome. This article discusses the unique characteristics of robotic-assisted surgical practice and approaches teams and organizations can take to enhance communication that supports a safe care culture.
McCarthy SE, Hogan C, Jenkins L, et al. BMJ Open Qual. 2023;12:e002270.
Debriefing after significant clinical events helps affected staff develop a shared mental model of what happened, why it happened, and how it can be prevented in the future. This paper describes development of training videos on after action reviews (AAR)s, a type of debriefing. The videos introduce AAR, show a simulated AAR debriefing, offer techniques for handing challenging situations within an AAR, and reflections on the benefits. The videos are available with the online version of the paper.
Gabbay‐Benziv R, Ben‐Natan M, Roguin A, et al. Int J Gynaecol Obstet. 2023;162:562-568.
Cyberattacks on healthcare systems are a rare but serious threat to public and patient safety. This article describes one obstetric department's experience with a weeklong cyberattack. Nearly every aspect of clinical care and monitoring was impacted, particularly loss of historical health record and electronic fetal heartrate monitoring. Adaptations to these and other affected services are detailed.
Wells M, Henry B, Goldstein L. Prehosp Disaster Med. 2023;38:471-484.
Inaccurate estimations of patient weight can lead to medication errors in the prehospital period. This systematic review of 9 studies concluded that there is insufficient evidence to assess the accuracy of weight estimation approaches used in the EMS setting or by paramedics, underscoring the need for additional, robust research in this area.
International Meeting/Conference
AHA Training. October 3-24, 2023. Tuesdays 2:00 PM - 3:30 PM (eastern).
Revisiting concept foundations is an important strategy to learn from experience and energize project participants. This virtual series will prepare participants to begin the implementation of the TeamSTEPPS program at their institutions and draw from the knowledge of others to make adjustments as needed to support teamwork training efforts.
Multi-use Website
Stratford, London; The National Guardian.
Organizational efforts to collect and respond to the concerns of staff and patients are a cornerstone to patient safety improvement despite challenges to implement them. This annual report presents insights drawn from problems staff share with Freedom to Speak Up Guardians in the United Kingdom to capitalize on problems to drive improvement. The 2023 report summarized data collected from over 25,000 cases recorded.
Newspaper/Magazine Article
West S. KFF Health News. August 24, 2023.
The challenge of unsafe maternal care is gaining deserved attention across the system spectrum. This article discusses the preventative nature of many barriers to safe care Black mothers face including lack of health insurance, limited access to prenatal care and disrespect for concerns during care encounters.
Organizational Policy/Guidelines
Geneva, Switzerland; International Council of Nurses: 2023.
Nursing is foundational to safe patient care. This statement outlines recommendations for the nursing community to support the World Health Organization Global Patient Safety Action Plan 2021-2030. Tactics described target, governmental, organizational, and individual actions for improvement.
Grant Announcement
Rockville, MD: Agency for Healthcare Quality and Research; August 22, 2023.
The articulation of diagnostic error in the ambulatory setting is emerging. These newly released funding announcements seek proposals that focus on understanding the factors contributing to diagnostic error and strategies to improve diagnostic safety in the ambulatory care environment. The application deadline for both opportunities has passed.
Audiovisual Presentation
Desjardins L. PBS NewsHour. August 29, 2023.
Disregard for women’s pain is a persistent problem in health care. This news segment discusses a podcast highlighting a pattern of dismissal of patient concerns that resulted in harm and allowed fentanyl diversion by a nurse with substance abuse disorder to go undetected.
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.
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 |
Editor’s note: 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 |
This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.
Stay Updated!
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. Sign up today to get weekly and monthly updates via emails!
