Email Updates
September 20, 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
Albanowski K, Burdick KJ, Bonafide CP, et al. AACN Adv Crit Care. 2023;34:189-197.
Alarm (or alert) fatigue occurs when clinicians ignore alarms, usually due to the majority being invalid or nonactionable, and thus fail to respond or respond more slowly to actionable alerts. The article describes the progress made in reducing nonactionable alarms and making actionable alarms more useful to responding clinicians. Clinical approaches include customization of alert parameters to reduce nonactionable alarms, while engineering solutions include reducing the volume or adjusting the tone of auditory alerts.
Loo VC, Kim S, Johnson LM, et al. J Patient Saf. 2023;19:460-464.
Ensuring the safety of clinical trial participants is paramount to successful, meaningful clinical research. In this study, researchers examined 585 clinical trial documents and found that 17% included potential patient safety interventions (e.g., resolving medication dosing discrepancies). The authors suggest that clinical specialists’ review of study protocol documents could enhance patient safety during clinical trial conduct.
Pitts SI, Olson S, Yanek LR, et al. JAMA Intern Med. 2023;183:1120-1126.
Previous research has found that CancelRx can improve communication between electronic health record (EHR) systems and pharmacy dispensing systems and increase successful medication discontinuation. This interrupted time series analysis assessed the impact of CancelRx implementation on successful discontinuation of medications e-prescribed in ambulatory healthcare settings. After CancelRx implementation, the proportion of e-prescriptions sold after discontinuation in the EHR decreased from 8.0% to 1.4%.
Gillette C, Perry CJ, Ferreri SP, et al. J Physician Assist Educ. 2023;34:231-234.
A study conducted in 2011 concluded that pharmacy students identified more prescribing errors than their medical or nursing counterparts. This study replicates the 2011 study with first- and second-year physician assistant (PA) students. The results suggest PA students, regardless of year, identified prescribing errors at similar rates to medical and nursing students, although identification rates were low for all three student groups.
van Sassen C, Mamede S, Bos M, et al. BMC Med Educ. 2023;23:474.
Clinical reasoning is an important component of medical education. In this study, first-year general practice residents concluded that diagnostic error cases, both with and without malpractice claim information, are equally effective for clinical reasoning education.
Rapp T, Sicsic J, Tavassoli N, et al. Eur J Health Econ. 2023;24:1085-1100.
Potentially inappropriate prescribing in long-term care facilities increases the risk of adverse drug events and other adverse outcomes, including increased healthcare costs. Based on a secondary data analysis from the Systematic Dementia Screening by Multidisciplinary Team Meetings in Nursing Homes for Reducing Emergency Department Transfers (IDEM) randomized trial, this study found that increases in potentially inappropriate prescribing increased residents’ risk of going to the emergency room and increased total medication spending.
Ivanovic V, Broadhead K, Beck R, et al. AJR Am J Roentgenol. 2023;221:355-362.
Like many clinical areas, a variety of system factors can influence diagnostic error rates in neuroradiology. This study included 564 neuroradiologic examinations with diagnostic error and 1,019 without error. Diagnostic errors were associated with longer interpretation times, higher shift volume, and weekend interpretation.
Amick AE, Schrepel C, Bann M, et al. Acad Med. 2023;98:1076-1082.
Disruptive behaviors, including experiencing or witnessing coworker conflict, can lead to staff burnout and adverse events. In this study, emergency medicine and internal medicine physicians reported on conflicts with other physicians they'd experienced in the workplace. Participants reported feeling demoralized and burnt out after a conflict and brought those feelings to future interactions, priming the situation for additional conflict.
Kramer JS, Hayley Burgess L, Warren C, et al. J Patient Saf Risk Manag. 2023;28:260-267.
Obtaining a best possible medication history (BPM) is an important component of successful medication reconciliation programs. This study compared the impact of a pharmacy-led medication reconciliation program including BPMH on adverse drug events (ADEs) and complications among high-risk, complex patients across 16 hospitals. In the six months following implementation, 80,000 reconciliations were completed and nearly 40% required additional medication follow-up and/or clarification. Researchers identified a statistically significant decrease in both ADEs and complications after implementation.
Jensen JF, Ramos J, Ørom M‐L, et al. J Clin Nurs. 2023;32:7530-7542.
Crisis (or crew) resource management (CRM) training focuses on improvement of non-technical skills such as communication, teamwork, and situational awareness. This quality improvement project consisted of simulation-based CRM training in the context of intensive care unit admission. Interviews with participants, conducted three months after the simulation, revealed several themes including reflections on patient safety. Participants described positive changes in workflow, professional standards, and smoother and controlled processes.
Pitts SI, Olson S, Yanek LR, et al. JAMA Intern Med. 2023;183:1120-1126.
Previous research has found that CancelRx can improve communication between electronic health record (EHR) systems and pharmacy dispensing systems and increase successful medication discontinuation. This interrupted time series analysis assessed the impact of CancelRx implementation on successful discontinuation of medications e-prescribed in ambulatory healthcare settings. After CancelRx implementation, the proportion of e-prescriptions sold after discontinuation in the EHR decreased from 8.0% to 1.4%.
Loo VC, Kim S, Johnson LM, et al. J Patient Saf. 2023;19:460-464.
Ensuring the safety of clinical trial participants is paramount to successful, meaningful clinical research. In this study, researchers examined 585 clinical trial documents and found that 17% included potential patient safety interventions (e.g., resolving medication dosing discrepancies). The authors suggest that clinical specialists’ review of study protocol documents could enhance patient safety during clinical trial conduct.
Choi JJ, Rosen MA, Shapiro MF, et al. Diagnosis (Berl). 2023;10:363-374.
Teamwork is increasingly seen as an important component of diagnostic excellence. Through a systematic review and observations of team dynamics in a hospital medical ward, researchers identified three areas requiring additional research- (1) team structure, (2) contextual factors, and (3) emergent states (e.g., shared mental models).
Samuelson-Kiraly C, Mitchell JI, Kingston D, et al. Healthc Manage Forum. 2024;37:9-12.
The threat of cybersecurity risks to patient safety is receiving increasing attention. This article describes the development of a new standard to support cyber resiliency in Canada’s healthcare system. The guidance addresses key areas of concern (e.g., organizational risk management, technology considerations, contingency planning), provides suggested roles and responsibilities for an organizational cybersecurity team, and emphasizes the importance of cyber incident response planning.
Schulman PR. Safety Sci. 2023;167:106279.
Organizational resilience and high reliability principles take a proactive approach to ensuring patient safety. Using a safety science perspective, this article highlights key features of organizational and network reliability and resilience and the challenges in applying these features to complex systems.
Albanowski K, Burdick KJ, Bonafide CP, et al. AACN Adv Crit Care. 2023;34:189-197.
Alarm (or alert) fatigue occurs when clinicians ignore alarms, usually due to the majority being invalid or nonactionable, and thus fail to respond or respond more slowly to actionable alerts. The article describes the progress made in reducing nonactionable alarms and making actionable alarms more useful to responding clinicians. Clinical approaches include customization of alert parameters to reduce nonactionable alarms, while engineering solutions include reducing the volume or adjusting the tone of auditory alerts.
Kane J, Munn L, Kane SF, et al. J Gen Intern Med. 2023;38:3406-3413.
Clinicians and staff are encouraged to speak up about safety concerns as a part of patient safety culture. This review had two aims: to review the literature on speaking up for patient safety, and to develop a single definition of "speaking up" in healthcare. 294 articles were identified with 51 directly focused on speaking up and the remaining on other aspects such as communication. 11 distinct definitions were identified from which the authors developed a single definition: a healthcare professional identifying a concern that might impact patient safety and using his or her voice to raise the concern to someone with the power to address it.
Imes CC, Tucker SJ, Trinkoff AM, et al. Nurs Adm Q. 2023;47:E38-E53.
Extended and overnight shifts are associated with higher adverse event rates and burnout. This mini review summarizes the impact of overnight shifts on nurses' health, patient and public safety, and organizational costs (e.g., those related to nurse turnover). Organizational strategies to promote nurses' health and reduce errors are also summarized, ranging from low-cost measures such as breaks for physical activity during the shift to high-cost measures such as referral to sleep specialists or paid transportation home.
No results.
Newspaper/Magazine Article
Peterson M. Los Angeles Times. September 5, 2023.
Safe practice in community pharmacy is challenged by production pressure, workforce shortages, and multitasking. This story examined the mistakes made at major retail pharmacy chains in California. It provides examples perpetrated across the industry to target universal areas of needed improvement and potential strategies to address them.
Multi-use Website
World Health Organization.
The sharing of best practices is a key component of enabling successful strategy implementation in support of patient safety plans and goals. This website will capture, organize, and share experiences worldwide to support knowledge sharing and community building to reduce World Patient Safety Day targeted challenges.
Newspaper/Magazine Article
Fortis B, Bell L. Pro Publica. September 12, 2023.
Sexual abuse of a patient is a never event. This article discusses how criminal behavior remained latent at a large health system due to persistent disregard of patient concerns, which enabled a serial sexual abuser to continue to practice medicine. The harm to the victims and fear of the peers who knew of the situation and were not psychologically safe enough to report it, are discussed.
Audiovisual
Graedon T. People’s Pharmacy. Show 1355. September 8, 2023.
Misdiagnosis continues to impact the safety of health care. This podcast with David Newman-Toker discusses foundational issues that detract from diagnostic safety and examines how teamwork, training, technology, and tuning can make the process more reliable. Strategies for patients to play a role in their diagnostic process are also discussed.
Special or Theme Issue
Health Affairs Forefront; May-September 2023.
Diagnostic delays stem from both human and process failures. This series of articles examines how strategies such as behavioral design, internet use, and prehospital practice play a role in the timing of diagnosis.
Newspaper/Magazine Article
Leonard A. KFF Health News. September 12, 2023.
The use of artificial intelligence (AI) holds potential for health care improvement that is beginning to be documented. This article discusses ChatGPT in the context of wide availability of internet search tools as a mechanism for patients to find answers to clinical questions. It summarizes clinicians’ concerns about the tools and strategies to being used to ensure the accuracy and safety of these searches.
This Month’s WebM&Ms
WebM&M Cases
Hana Camarillo, PharmD, BCACP, CDCES |
A 14-year-old girl was admitted to the hospital with a new diagnosis of type 1 diabetes mellitus without ketoacidosis. Before discharge, medications intended for home use were delivered to the patient’s bedside, but the resident physician noticed a discrepancy. An insulin pen and pen needles had been ordered, but an insulin vial and extra insulin syringes were delivered. Neither the patient nor the parents had received education on how to draw up and administer insulin using a vial and syringe. The pharmacy staff reported that the insulin pen was out of stock, so the insulin vial was substituted because it contained the same active ingredient. The insulin product switch was declined, and another pharmacy was contacted to provide the insulin pen, which was delivered to the patient’s bedside the following day. The commentary summarizes the patient safety risks associated with drug shortages, drug interoperability standards, and the importance of clear communication between members of the care team if alternative therapies need to be considered
WebM&M Cases
Commentary by Alyssa Bellini, MD and Edgardo S Salcedo, MD, FACS |
This case highlights two “never events” involving the same patient. A first-year orthopedic surgery resident was consulted to aspirate fluid from the left ankle of a patient in the intensive care unit. The resident, accompanied by a second resident, approached the wrong patient and inserted the needle into the patient’s right ankle. At this point, a third resident entered the room and stated that it was the incorrect patient. The commentary highlights the importance of a proper time out and approaches to improve communication among all members of the care team.
WebM&M Cases
Liliya Klimkiv, MD, Garth Utter, MD, MSc, and David K. Barnes, MD |
This case describes an older adult patient with generalized abdominal pain who was eventually diagnosed with inoperable bowel necrosis. Although she appeared well and had stable vital signs, triage was delayed due to emergency department (ED) crowding, which is usually a result of hospital crowding. She was under-triaged and waited three hours before any diagnostic studies or interventions commenced. Once she was placed on a hallway gurney laboratory and imaging studies proceeded hastily. Catastrophic bowel necrosis was eventually identified, yet she was not moved to a standard ED treatment bed for another 25 minutes. Despite aggressive resuscitation, the surgeon determined that operative intervention was futile, and the patient died a short time later. The commentary highlights how hospital crowding and ED boarding can lead to delayed triage and inefficient ED throughput, which compromises patient safety and summarizes approaches to improving ED triage and throughput.
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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