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October 4, 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
Classen DC, Longhurst CA, Davis T, et al. JAMA Netw Open. 2023;6:e2333152.
Electronic health records (EHR) with computerized provider order entry (CPOE) help prevent many types of medication errors but poor user design can hinder these benefits. Using scores from the National Quality Forum Leapfrog Health IT Safety Measure and the ARCH Collaborative EHR User experience survey, this study compares safety scores and physician perceptions of usability. Results indicate a positive association between safety performance and user experience, affirming the importance of user-centered design.
Essa CD, Victor G, Khan SF, et al. Am J Emerg Med. 2023;73:63-68.
Emergency department triage nurses use their knowledge, experience, expertise, and critical thinking skills to prioritize patients by severity, ensuring the sickest patients are seen first. This study sought to identify cognitive biases that may negatively impact nurses' triage decision making. In a scenario describing a patient at Emergency Severity Index (ESI) level 1, the highest level, only 51% of nurses selected the cognitively unbiased triage response.
Huth K, Hotz A, Emara N, et al. J Patient Saf. 2023;19:493-500.
The transition from hospital to home is a vulnerable time as patients may have changes in medications or care needs, or difficulties accessing follow up with an outpatient provider. To reduce adverse events (AE), rehospitalizations, and emergency department visits, this hospital developed a structured discharge bundle based on the I-PASS tool used for inpatient handoffs. AE, rehospitalizations, and emergency department visits were all reduced following implementation of the I-PASS bundle.
Phillips KK, Mecca MC, Baim‐Lance AM, et al. J Am Geriatr Soc. 2023;71:2935-2945.
Polypharmacy is a common patient safety concern among veterans. In this study, 21 Veterans Health Administration (VA) sites developed their own deprescribing protocols and participated in a virtual deprescribing collaborative. Sites employed decision support tools, such as the VA VIONE tool, and other strategies, such as individualized medication review, to encourage deprescribing and reduce polypharmacy among its patients.
Longo BA, Schmaltz SP, Williams SC, et al. Jt Comm J Qual Patient Saf. 2023;49:511-520.
Supporting and improving clinician well-being has long been a safety focus and received renewed focus during the COVID-19 pandemic. This study sought to understand efforts undertaken to support clinicians’ well-being in Joint Commission-accredited hospitals and Federally Qualified Health Centers (FQHC). Only half of responding hospitals and FQHCs reported implementing at least one action towards improving clinician well-being (e.g., establishing a wellness committee) and few had implemented a comprehensive approach.
Essa CD, Victor G, Khan SF, et al. Am J Emerg Med. 2023;73:63-68.
Emergency department triage nurses use their knowledge, experience, expertise, and critical thinking skills to prioritize patients by severity, ensuring the sickest patients are seen first. This study sought to identify cognitive biases that may negatively impact nurses' triage decision making. In a scenario describing a patient at Emergency Severity Index (ESI) level 1, the highest level, only 51% of nurses selected the cognitively unbiased triage response.
Chekmeyan M, Baccei SJ, Garwood ER. J Am Coll Radiol. 2023;20:1225-1230.
Artificial intelligence (AI) has become a useful tool to support radiologists in diagnostic imaging. In this study, discordant findings between the radiologist and AI (negative by radiologist report, positive by AI report, with unviewed AI decision support system output) triggered an automatic manual review of the diagnostic images. More than 111,000 CT studies were analyzed, with 46 triggering the automatic review; of those, 26 (0.02%) were true positives (i.e., missed diagnosis by radiologist but identified by AI).
McCoy C, Keshvani N, Warsi M, et al. BMJ Open Qual. 2023;12:e002220.
In-hospital cardiac arrests (IHCAs) are complex clinical scenarios requiring effective communication and teamwork. This study assessed the impact of a bundled, multicomponent intervention to empower telemetry technicians and improve communication between telemetry technicians and other clinicians during in-hospital cardiac arrest. After bundle implementation, researchers observed improvements in IHCA survival.
Minors AM, Yusaf TC, Bentley SK, et al. Simul Healthc. 2023;18:226-231.
In situ simulations offer unique opportunities to improve teamwork and identify system vulnerabilities. This study examined risks – “no go” considerations - associated with in situ simulations focused on cardiac arrest in pregnancy and identified factors that could lead simulations to be canceled or postponed to ensure patient or staff safety.
van Sassen CGM, van den Berg PJ, Mamede S, et al. Adv Health Sci Educ Theory Pract. 2023;28:893-910.
Improving clinical reasoning is an important component of medical education. Using a medical malpractice claims database, researchers in this study reviewed 50 conditions identified 15 priority conditions that can be used to improve clinical reasoning education for general practitioners. The conditions represent common (e.g., eye infection), complex common (e.g., renal insufficiency, cardiovascular disease, cancer), and complex rare conditions (e.g., ectopic pregnancy) and often demonstrate atypical presentations or complex contextual factors important for diagnostic reasoning.
Classen DC, Longhurst CA, Davis T, et al. JAMA Netw Open. 2023;6:e2333152.
Electronic health records (EHR) with computerized provider order entry (CPOE) help prevent many types of medication errors but poor user design can hinder these benefits. Using scores from the National Quality Forum Leapfrog Health IT Safety Measure and the ARCH Collaborative EHR User experience survey, this study compares safety scores and physician perceptions of usability. Results indicate a positive association between safety performance and user experience, affirming the importance of user-centered design.
Huth K, Hotz A, Emara N, et al. J Patient Saf. 2023;19:493-500.
The transition from hospital to home is a vulnerable time as patients may have changes in medications or care needs, or difficulties accessing follow up with an outpatient provider. To reduce adverse events (AE), rehospitalizations, and emergency department visits, this hospital developed a structured discharge bundle based on the I-PASS tool used for inpatient handoffs. AE, rehospitalizations, and emergency department visits were all reduced following implementation of the I-PASS bundle.
Levy BE, Wilt WS, Lantz S, et al. J Patient Saf. 2023;19:453-459.
The surgical time out is an effective strategy to reduce errors and improve team communication but full team participation remains a challenge. This article describes a Plan, Do, Study, Act project of developing and implementing a white board time out checklist to encourage all operating room personnel to participate. A significant increase in the number of completed time out items was seen after implementation.
Soenens G, Marchand B, Doyen B, et al. Ann Surg. 2023;278:e5-e12.
Leadership style can dramatically impact the culture of safety. This analysis of video-recorded endovascular procedures found that surgeons’ transformational leadership style (e.g., motivation/enthusiasm, individual consideration, emphasis on the collective mission) positively impacts team behaviors such as speaking up behaviors and knowledge sharing.
Rao A, Heidemann LA, Hartley S, et al. Clin Teach. 2024;21:e13630.
Accurate and complete clinical documentation is essential to high quality, safe healthcare. In this simulation study, senior medical residents responded to pages regarding sepsis or atrial fibrillation (phone encounter) and documented a brief note regarding the encounter afterwards (documentation encounter). The study found that written documentation following a clinical encounter included more important clinical information (e.g., ordering blood cultures for sepsis, placing a patient on telemetry) compared to what was discussed during the phone encounter.
Parry D, Odedra A, Fagbohun M, et al. Br J Oral Maxillofac Surg. 2023;61:509-513.
Misleading or unclear abbreviations can cause communication errors and threaten patient safety. This article highlights how lessons learned regarding abbreviations in aviation can apply to healthcare to avoid abbreviation-related medical errors, such as prescribing errors.
Wu AW, Papieva I, Sheridan S, et al. J Patient Saf Risk Manag. 2023;28:147-152.
True partnership with patients and families in safety work is an important yet elusive goal. This commentary outlines elements supporting engagement as part of an ambitious global plan and awareness campaign to ensure medical error reduction efforts are fully informed and enriched through the application of the patient and family experience in health care.
Marsch A, Khodosh R, Porter M, et al. J Am Acad Dermatol. 2023;89(4):641-54; 57-67.
Patient safety in dermatology has received increasing attention over the past ten years. Part 1 of this series provides examples of patient safety concerns in dermatology (e.g., medication errors, teledermatology) and how key patient safety concepts such as safety culture and root cause analysis can be applied in dermatology settings. Part 2 of this series applies three quality improvement frameworks (LEAN, Six Sigma, and IHI-QI) can be used to improve the quality and safety of dermatology practice.
Harrison J. Br Paramed J. 2023;8:18-28.
Patients with dark skin tones are not well represented in health education, particularly dermatology, which can result in delayed diagnosis. In this scoping review, thirteen articles were identified assessing the confidence of students and healthcare providers in assessing patients with dark skin tones. Overall, confidence was low but tailored training somewhat improved confidence. The author asserts more research and education is needed outside dermatology, for example, when assessments use terms such as pale, redness, or blue.
International Meeting/Conference
Washington DC: The Leapfrog Group; 2023.
Diagnostic errors in hospitals are the focus on continued improvement efforts as they are common, costly, and harmful. This three-part series of webinars focused on foundations, reduction activities and existing learning strategies to improve diagnosis in hospitals.
Newspaper/Magazine Article
Landro L. Wall Street Journal. September 24, 2023.
Artificial intelligence (AI) is being considered as a strong contender in the effort to reduce harmful diagnostic error, but concerns as to its use exist. This article discusses how physician experience can help to address AI’s lack of ability to read nuance, data weaknesses, workflow disruptions, and biased algorithms if they except the tool’s strengths to enhance the accuracy of their practice.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute Care edition. 2023;28(19):1-3.
Lack of experience with distinct processes and products can lay the foundation for mistakes. This article examines an instance when a colonoscopy preparation product was switched with a dialysis fluid, a barcoding system didn’t recognize the substitution, and a patient died. Barcode identification, solution availability and staffing improvements are discussed to minimize opportunities for the systemic failures contributing to harm.
Audiovisual Presentation
Plymouth Meeting PA, ECRI. 2019-2023.
A wide variety of considerations must converge to inform an understanding of system vulnerabilities and the application of strategies to address them. This series of webinars covers a range of topics affecting the reliability of the health care environment. A recent presentation discussed the “5 rights of medication safety.”
Audiovisual Presentation
McDonald T. TEDxSanDiego. September 23, 2023.
The lack of a safety culture fundamentally restricts the ability of clinicians to address mistakes, psychologically deal with them and learn. The CANDOR system is highlighted in this presentation by one of the originators of the concept as a strategy for successful resolution, learning and support for those involved in medical error.
This Month’s WebM&Ms
WebM&M Cases
Nidhi Patel Jain, PharmD, MBAc and David Dakwa, PharmD, MBA, BCPS, BCSCP |
A 2-year-old girl presented to the emergency department (ED) with joint swelling and rash following an upper respiratory infection. After receiving treatment and being discharged with a diagnosis of allergic urticaria, she returned the following day with worsening symptoms. Suspecting an allergic reaction to amoxicillin, the ED team prepared to administer methylprednisolone. However, the ED intake technician erroneously switched the patient’s height and weight in the electronic health record (EHR), resulting in an excessive dose being ordered and dispensed. An automatic error message was generated due to the substantial difference from previous weights, but this message was overlooked by the ED technician and the data entry error was not detected or corrected. The commentary discusses the importance of verifying medication orders before administration, optimizing alert notifications to minimize the risk of alert fatigue, and the role of root cause analysis to identify factors contributing to medication error
WebM&M Cases
Hang Mieu Ha, DO and Kristin Alexis Olson, MD |
A 32-year-old man presented to the hospital with a comminuted midshaft femoral fracture after a bicycle accident. Imaging suggested the fracture was pathologic and an open biopsy specimen was submitted to pathology for intraoperative consultation. However, this procedure was followed by a series of events that increased the likelihood for harm, including the inability to provide a definitive diagnosis at the time of frozen section examination, the subsequent delayed diagnosis, lack of cross coverage for leave among care team members, and poor communication and handoffs.
WebM&M Cases
Scott MacDonald, MD |
This WebM&M describes two cases illustrating several types of Electronic Health Record (EHR) errors, with a common thread of erroneous use of electronic text-generation functionality, such as copy/paste, copy forward, and automatically pulling information from other electronic sources to populate clinical notes. The commentary discusses other EHR-based documentation tools (such as dot phrases), the influence of new documentation guidelines, and the role of artificial intelligence (AI) tools to capture documentation.
This Month’s Perspectives
Interview
Cheryl B. Jones, PhD, RN, FAAN |
Cheryl B. Jones is a professor, director of the Hillman Scholars Program, and interim associate dean of the School of Nursing’s PhD program at the University of North Carolina at Chapel Hill. We spoke to her about workplace violence trends in healthcare settings and how we can create a safer work environment for healthcare staff.
Perspectives on Safety
Cheryl B. Jones, PhD, RN, FAAN; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD |
This piece focuses on workplace violence trends in healthcare settings and strategies for creating a safer healthcare environment.
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