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October 11, 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
Congenie K, Bartjen L, Gutierrez D, et al. Jt Comm J Qual Patient Saf. 2023;49:716-723.
Simulations are routinely used to identify latent safety threats. This article describes the classification of 1,318 latent safety threats identified from 232 simulations. Researchers were then able to issue site-specific and organization-wide standardized dashboards and summaries, thus allowing for local and systemwide improvements.
Kapoor A, Patel P, Mbusa D, et al. J Gen Intern Med. 2023;Epub Sep 27.
Pharmacists are frequently involved in medication reviews for hospitalized patients prescribed direct oral anti-coagulants (DOAC). This randomized controlled study explored pharmacist involvement with patients prescribed DOAC in ambulatory care. The intervention included up to three phone calls, electronic health record communication with the prescriber, and recommendations for lab work. After 90 days, there were no differences in clinically important medication errors between groups.
Michelson KA, McGarghan FLE, Waltzman ML, et al. Hosp Pediatr. 2023;13:e170-e174.
Trigger tools are commonly used to detect adverse events and identify areas for safety improvement. This study found that trigger tools using electronic health record-based data can accurately identify delayed diagnosis of appendicitis in pediatric patients in community emergency department (ED) settings.
Gupta AB, Greene MT, Fowler KE, et al. J Patient Saf. 2023;19:447-452.
As high workload and interruptions are known contributors to diagnostic errors, significant research has been conducted to understand and ameliorate the impact of these factors. This study examined the association between hospitalist busyness (i.e., number of admissions and pages), resource utilization, number of differential diagnoses, and the hospitalist's diagnostic confidence and subjective awareness. Increasing levels of busyness were associated with hospitalists reporting it was "difficult to focus on what is happening in the present" but had no effect on diagnostic confidence.
Arastehmanesh D, Mangino A, Eshraghi N, et al. J Emerg Med. 2023;65:e250-e255.
Characteristics inherent to the emergency department (ED), such as overcrowding and unfamiliar patients, make it susceptible to errors. This article describes a novel process for identification of ED errors by adding the question, "Would you have done something differently?" to the chart review process. Adding this question and requiring a detailed explanation of what they would have done differently allowed for differentiation between a true medical error and a judgment call that coincides with an adverse event. Near misses, adverse events, and adverse events attributable to error were significantly higher when reviewers would have done something differently.
Michelson KA, McGarghan FLE, Waltzman ML, et al. Hosp Pediatr. 2023;13:e170-e174.
Trigger tools are commonly used to detect adverse events and identify areas for safety improvement. This study found that trigger tools using electronic health record-based data can accurately identify delayed diagnosis of appendicitis in pediatric patients in community emergency department (ED) settings.
Teigné D, Cazet L, Birgand G, et al. Int J Qual Health Care. 2023;35:mzad069.
Interruptions and distractions can diminish the quality and safety of care and lead to preventable medical errors. This observational study characterized interruptions affecting 23 care teams working in medical or surgical specialties across 17 sites in France. The researchers estimated that, on average, professionals were interrupted 10.5 times per hour, and that 57% of interruptions were avoidable.
Congenie K, Bartjen L, Gutierrez D, et al. Jt Comm J Qual Patient Saf. 2023;49:716-723.
Simulations are routinely used to identify latent safety threats. This article describes the classification of 1,318 latent safety threats identified from 232 simulations. Researchers were then able to issue site-specific and organization-wide standardized dashboards and summaries, thus allowing for local and systemwide improvements.
Kapoor A, Patel P, Mbusa D, et al. J Gen Intern Med. 2023;Epub Sep 27.
Pharmacists are frequently involved in medication reviews for hospitalized patients prescribed direct oral anti-coagulants (DOAC). This randomized controlled study explored pharmacist involvement with patients prescribed DOAC in ambulatory care. The intervention included up to three phone calls, electronic health record communication with the prescriber, and recommendations for lab work. After 90 days, there were no differences in clinically important medication errors between groups.
Eldor L, Hodor M, Cappelli P. Org Behav Human Decision Proc. 2023;177:104255.
Psychological safety is the idea that team members can take risks, such as voicing concerns or putting forth innovative ideas, and is considered a vital part of robust safety culture. This article describes the relationship between psychological safety and in-role performance in nursing and four other organizational settings. Results suggest routine task performance increases with psychological safety only to a point, then declines. The authors describe collective accountability to offset the decline in task performance.
Liberati EG, Martin GP, Lamé G, et al. BMJ Qual Saf. 2023;Epub Sep 21.
“Safety cases” are used in healthcare and other industries to communicate the safety of a product, system, or service. In this study, researchers use the “safety case” approach to evaluate the safety of the Safer Clinical Systems program, which is designed to improve the safety and reliability of clinical pathways.
Cullati S, Semmer NK, Tschan F, et al. Int J Public Health. 2023;68:1606078.
Illegitimate tasks are those that workers think they should not have to perform, either because they are unnecessary or not part of their specific role. In this study with hospital nurses, physicians, and other direct and indirect healthcare staff, 20% reported illegitimate tasks occurred frequently in their setting. Although respondents were not asked to specify illegitimate tasks, the authors hypothesize that physicians, who reported the highest prevalence of frequency of illegitimate tasks, may perceive "administrative" tasks as illegitimate.
Organizational Policy/Guidelines
Bauer ME, Albright C, Prabhu M, et al. Obstet Gynecol. 2023;142:481-492.
Reducing maternal morbidity and mortality is a critical patient safety priority. Developed by the Alliance for Innovation on Maternal Health (AIM), this patient safety bundle provides guidance for healthcare teams to improve the prevention, recognition, and treatment of infections and sepsis among pregnant and postpartum patients.
Herrera H, Wood D. Crit Care Nurs Clin North Am. 2023;35:347-355.
Children in the pediatric intensive care unit (PICU) require constant monitoring to detect early signs of worsening conditions. While these alerts from the monitors allow nurses and other staff to quickly intervene, alarm fatigue may set in, resulting in delayed responses. This article describes several causes for nonactionable or false alarms and makes recommendations to address them.
Richards JL, Brook K. Postgrad Med J. 2023;Epub Sep 19.
Healthcare organizations are implementing various interventions to reduce clinician burnout and mitigate associated harms. This article describes the influence of financial wellness on physician burnout and suggests that medical schools and healthcare organizations implement strategies to increase physician financial literacy as one approach to reducing burnout.
Harbell MW, Maloney J, Anderson MA, et al. Curr Pain Headache Rep. 2023;27:407-415.
Provider bias may impact the pain management patients receive post-operatively. This review presents recent findings on the types and amounts of pain management patients receive. Results suggest women and people of color receive less pain medication despite reporting higher pain scores. Results regarding socio-economic status and English language proficiency bias are mixed. Implicit bias training, prescribing guidelines for all patients, and culturally competent pain management scales have all been suggested as ways to reduce provider bias and improve pain management.
Schuessler N, Glarcher M. J Hosp Palliat Nurs. 2023;Epub Sep 25.
Telehealth can expand patient access to care and improve patient experience. This integrative review including nine studies explored the tele-palliative care options available for caregivers, factors influencing the sustainability of tele-palliative care interventions, and patient safety considerations (e.g., data security, communication challenges).
Tan MZY, Prager G, McClelland A, et al. BMJ Open. 2023;13:e072136.
Resilience in healthcare focuses on enabling individuals and teams to respond to emergent problems without compromising safety. This review-of-reviews examines the definitions of resilience across the hierarchical levels of healthcare (e.g., individual, team, organizational, community). The authors describe an interdisciplinary, cross-sectoral, multi-level conceptual framework for healthcare resilience which includes resilience activities before, during, after, and across events.
Ryan AN, Robertson KL, Glass BD. Int J Clin Pharm. 2023;Epub Sep 9.
Look-alike medications can cause confusion and contribute to medication administration errors. This scoping review including 18 articles identified several risk reduction strategies to mitigate look-alike medication errors in perioperative settings, such as improved labelling and standardization of storage. The authors note that further research is needed to assess the effectiveness of technology-based solutions, such as automated dispensing cabinets.
Samost-Williams A, Rosen R, Hannenberg A, et al. Ann Surg Open. 2023;4:e321.
Morbidity and mortality conferences offer important opportunities for healthcare teams to discuss adverse events, learn from errors, and improve patient safety. This systematic review examined beneficial aspects of perioperative team-based morbidity and mortality (TBMM) conferences. The authors found that TBMM conferences generally led to improvements in patient safety, quality improvement, and educational outcomes and that certain factors (case preparation, standardized presentation format, effective facilitation) increase TBMM benefits.
International Meeting/Conference
ECRI and the Institute for Safe Medication Practices. November 14, 2023, 12:00-5:00 PM (eastern).
Failure mode and effect analysis (FMEA) is a proactive method to identify risks at each step in the process. Attendees of this training will learn how and why healthcare FMEA is performed, and apply their learning to case studies.
Kendir C, Fujisawa R, Brito Fernandes O, et al. Paris, France: OECD Publishing; 2023. OECD Health Working Papers, No. 159.
Patient and family engagement can improve individual health outcomes and may help identify potential safety hazards. This report describes the economic impact of patient engagement, results of pilot data collection to measure patient-reported experiences of safety, and the status of patient engagement in 21 countries.
Newspaper/Magazine Article
Tanski MC. Pharmacy Times Health Systems edition. September 2023;12(5):34-35.
Medication reconciliation should be completed at admission, discharge, and during transitions of care. This article describes the impacts of pharmacist involvement, including lower hospital readmissions and post-discharge adverse events.
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 |
Editor’s note: 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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