Email Updates
October 18, 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
Kalfsvel L, Wilkes S, van der Kuy H, et al. Eur J Hosp Pharm. 2023;Epub Aug 31.
Even with the use of clinical decision support systems (CDSS), clinicians can still make medication prescribing errors. This study compared frequency, type, and severity of prescribing errors between junior doctors (i.e., those in training with less than 10 years’ work experience) and consultants (i.e., not in training with 10 or more years of work experience). Overall prescribing errors were low, but junior doctors made more errors than consultants. They also made different types of errors, with junior doctors more likely to make drug-drug interaction errors and consultants making duplication therapy errors. There were no differences in severity of errors. Early education and training with computerized provider order entry (CPOE) and CDSS may reduce errors made by doctors in training.
Klopotowska JE, Leopold J‐H, Bakker T, et al. Br J Clin Pharmacol. 2024;90:164-175.
Identifying and preventing drug-drug interactions (DDI) is critical to patient safety, but the usual method of detecting DDI and other errors - manual chart review - is resource intensive. This study describes the use of an e-trigger to pre-select charts for review that are more likely to include one of three DDIs, thus reducing the overall number of charts needing review. Two of the DDI e-triggers had high positive predictive values (0.76 and 0.57), demonstrating that e-triggers can be a useful method to pre-selecting charts for manual review.
Zimbro KS, Bridges C, Bunn S, et al. J Nurs Care Qual. 2023;Epub Oct 2.
Inpatient falls are a persistent patient safety concern. In this study, researchers analyzed electronic health record (EHR) data from a 13-hospital health care system to examine whether remote patient monitoring can reduce inpatient falls. Findings indicate that remote patient monitoring (when combined with standard fall precautions) can reduce the incidence of falls and fall-related injuries, as well as decrease fall-related expenditures.
Ljungberg Persson C, Nordén Hägg A, Södergård B. Explor Res Clin Soc Pharm. 2023;12:100327.
Increases in clinician workload can increase the risk of medical errors. This survey of Swedish community pharmacists found that while perceived workload increased and work environment decreased during the COVID-19 pandemic, there was no perceived impact on patient safety. Findings underscore the importance of effective communication between management and frontline healthcare workers during crises.
Klopotowska JE, Leopold J‐H, Bakker T, et al. Br J Clin Pharmacol. 2024;90:164-175.
Identifying and preventing drug-drug interactions (DDI) is critical to patient safety, but the usual method of detecting DDI and other errors - manual chart review - is resource intensive. This study describes the use of an e-trigger to pre-select charts for review that are more likely to include one of three DDIs, thus reducing the overall number of charts needing review. Two of the DDI e-triggers had high positive predictive values (0.76 and 0.57), demonstrating that e-triggers can be a useful method to pre-selecting charts for manual review.
Moyal-Smith R, Etheridge JC, Turley N, et al. BMJ Qual Saf. 2024;33:223-231.
Implementation challenges can hinder the effectiveness of the WHO Surgical Safety Checklist (SSC). This study describes the validation of the Checklist Performance Observation for Improvement (CheckPOINT) tool to assess SSC implementation fidelity. Based on testing in simulated and real-life clinical practice, researchers found that that the tool can reliably assess implementation fidelity and identify opportunities for improvement.
Castro R da NS de, Aguiar LB de, Volpe CRG, et al. Int J Environ Res Public Health. 2023;20:6788.
Medication errors not only harm patients and increase hospital length of stay, but they are also an economic burden to patients and the health system. This study describes the types of medication errors and related costs in a Brazilian adult intensive care unit (ICU). The most common error type was omission, accounting for half of all errors. Scheduling and prescription errors were significantly correlated with increased hospitalization costs. Additionally, some medication doses contained more than one error type, driving up costs even further.
Bagian JP, Paull DE, DeRosier JM. Surg Open Sci. 2023;16:33-36.
The Accreditation Council for Graduate Medical Education (ACGME) requires post-graduate education to include patient safety curriculum. This article describes the development and evaluation of a curriculum for residents on patient safety investigations using the Root Cause Analysis and Action (RCA2) model. Residents were surveyed at least one year after completion of the training. Sixty-three percent of respondents agreed or strongly agreed residents should be provided with the RCA2 training and nearly half reported having participated on an RCA team since completing the program.
Kalfsvel L, Wilkes S, van der Kuy H, et al. Eur J Hosp Pharm. 2023;Epub Aug 31.
Even with the use of clinical decision support systems (CDSS), clinicians can still make medication prescribing errors. This study compared frequency, type, and severity of prescribing errors between junior doctors (i.e., those in training with less than 10 years’ work experience) and consultants (i.e., not in training with 10 or more years of work experience). Overall prescribing errors were low, but junior doctors made more errors than consultants. They also made different types of errors, with junior doctors more likely to make drug-drug interaction errors and consultants making duplication therapy errors. There were no differences in severity of errors. Early education and training with computerized provider order entry (CPOE) and CDSS may reduce errors made by doctors in training.
Marlett JE, Vacovsky BA, Krug EA, et al. Worldviews Evid Based Nurs. 2024;20:634-641.
Elopement represents a serious threat to patient safety and requires a system-wide, organized response. This article describes the development and implementation of an organizational elopement management plan featuring an elopement risk evaluation and elopement response algorithm. After implementation, the number of elopements occurring over a six-month period decreased from 34 to 12 events and the average duration of each event decreased from 118 minutes to 24 minutes.
Kaya S, Banaz Goncuoglu M, Mete B, et al. J Patient Saf. 2023;19:439-446.
Safety culture is associated with increased error reporting, improved teamwork, and decreases in patient harm. This study used the Safety Attitudes Questionnaire to explore the relationship between the dimensions of safety culture and four outcomes: making an error, witnessing an error, incident reporting, and patient safety grade. The strongest dimension of safety culture was teamwork climate and the lowest was perceptions of management. Patient safety grade and overall safety culture were strongly positively associated.
Huang KX, Chen CK, Pessegueiro AM, et al. J Hosp Med. 2023;18:888-895.
Interdisciplinary rounds have been shown to improve patient outcomes such as shorter length of stay. In this study, more than 1,000 interdisciplinary rounds were observed to assess the extent and timing of physician-nurse communication. Results show attending physicians had longer interaction times with nurses than did residents or interns. Attendings were also more likely to elicit nurses' concerns rather than waiting for nurses to bring them up. These findings show the importance of including attendings in bedside rounds and medical schools could stress the importance of interdisciplinary rounds and teamwork.
Young RA, Gurses AP, Fulda KG, et al. BMJ Open Qual. 2023;12:e002350.
Improving medication safety in ambulatory care settings is a patient safety priority. This qualitative study with primary care teams across four sites in the southwestern United States explored approaches to improving medication safety. Respondents emphasized the importance of customization and individualization (e.g., simplifying medication regimens for certain patients) and described how the principles of high reliability can help teams anticipate and respond to medication safety risks.
Lamoureux C, Hanna TN, Callaway E, et al. Emerg Radiol. 2023;30:577-587.
Clinician skills can decrease with age. This retrospective analysis of 1.9 million preliminary interpretations of radiology imaging findings examined the relationship between radiologist age and diagnostic errors. While the overall mean error rate for all radiologists was low (0.5%), increasing age was associated with increased relative risk of diagnostic errors.
Zimbro KS, Bridges C, Bunn S, et al. J Nurs Care Qual. 2023;Epub Oct 2.
Inpatient falls are a persistent patient safety concern. In this study, researchers analyzed electronic health record (EHR) data from a 13-hospital health care system to examine whether remote patient monitoring can reduce inpatient falls. Findings indicate that remote patient monitoring (when combined with standard fall precautions) can reduce the incidence of falls and fall-related injuries, as well as decrease fall-related expenditures.
Harmon CS, Adams SA, Davis JE, et al. Appl Nurs Res. 2023;73:151724.
Electronic health records increase safety in many ways but are not without problems. In this survey, emergency department nurses reported that electronic health record (EHR) issues (downtime, workflow) negatively impacted patient safety such as documentation or orders placed on the wrong patient chart.
Shaikh U, Kim JM, Yin SH. Clin Pediatr (Phila). 2023;20:6788.
The American Academy of Pediatrics' Policy Statement, "Preventing Home Medication Administration Errors", called for improving medication safety at home for children with medical complexity. This article describes a toolkit for pediatricians to support implementation focusing on four interventions: establishing practice-based error reporting systems, standardizing medication reconciliation, improving communication, and integrating resources for patients and families. Of particular importance is the use of health literacy-informed, culturally sensitive resources.
O'Hara JK, Canfield C. Lancet. 2023;403:791-793.
Specialization, setting-specific emphasis of improvement actions and task-oriented production pressures degrade patient-centeredness and safety. This commentary highlights the importance of involving patients in safety improvement efforts at both the clinical and operational levels to reduce structural barriers to high-quality care.
Yung AHW, Pak CS, Watson B. Int J Qual Health Care. 2023;35:mzad065.
Cognitive aids such as mnemonics can help improve process reliability and promote patient safety. Based on an initial scoping review, this article describes a proposed taxonomy for clinical handoff mnemonics and their clinical processes and functions, which could help clinical teams design handoff mnemonics that best fit their workplace.
No results.
Audiovisual Presentation
Chicago, IL: American Medical Association; 2023.
The vulnerability of healthcare information technologies and devices to malicious interruptions is increasingly recognized as a patient safety hazard. This eight-episode video series provides an overview for non-technologists on how cyberattacks happen, their potential to degrade care provision, and strategies to keep practices safe.
Newspaper/Magazine Article
Quick Safety. October 2023;70:1-2.
Pressure injuries are a significant and preventable patient safety threat. This article summarizes recommended actions to assist health care teams in mitigating harmful healthcare-acquired pressure ulcers including recognition of conditional risks and educational strategies.
Wolfe SW, Oshel RE. Washington, DC: Public Citizen; August 16, 2023.
There are recognized systemic weaknesses in identification and disciplinary programs addressing clinicians with poor performance records. This report examines the effectiveness of state medical-licensing boards as responsible parties to tracking problematic physicians. The reduction of variation in processes across various states, involvement of patients on review boards, and increased use of the National Practitioner Data Bank are suggested improvement strategies.
Edmondson A. Atria Books, New York, 2023. ISBN: 9781982195069.
Despite the harm that failure can cause, its value as a learning opportunity, if examined through the lens of human error rather than blame, cannot be understated. This book explores how failure that happens in new situations provides new insights toward goal achievement, utilizes knowledge and capitalizes on even small missteps, and can enhance and inform improvement.
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.
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!
