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October 25, 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
Foster M, MHA BS, Mazur L. BMJ Open Qual. 2023;12:e002284.
Healthcare leadership walkarounds (LWs) involve organizational leaders visiting hospital wards to hear directly from frontline staff about concerns and what is going well. This systematic review describes the impact of LWs on organizational and patient outcomes. Most studies (11 out of 12) measured organizational or clinical outcomes. Organizational outcomes included staff perception of safety culture, near miss reports, teamwork, and feeling heard. Only one study investigated the association between LWs and clinical outcomes; in that study, catheter-associated urinary tract infections decreased following implementation of LW.
Naya K, Aikawa G, Ouchi A, et al. PLoS One. 2023;18:e0292108.
Healthcare workers who are involved in patient safety incidents and experience adverse psychological or emotional outcomes are often referred to as second victims. This systematic review and meta-analysis found that 58% of healthcare workers in intensive care unit (ICU) settings have experienced second victim outcomes, including guilt, anxiety, anger at oneself, and decreased self-confidence. The review also found that one in five individuals took longer than 12 months to recover or did not recover at all, underscoring the importance of organizational support programs for healthcare workers involved in patient safety incidents.
Labrague LJ. Leadersh Health Serv (Bradf Engl). 2023;Epub Oct 9.
Leadership behaviors have an important impact on the workforce and work environment in both positive and negative ways. This review summarizes how toxic leadership impacts the nursing workforce and patient safety. Within the patient safety theme, toxic leadership was significantly associated with increased falls, nosocomial infections, and medication errors.
Alqenae FA, Steinke DT, Belither H, et al. Drug Saf. 2023;46:1021-1037.
Miscommunication between hospitals and community pharmacists at patient discharge can result in incorrect or incomplete medication distribution to patients. This study describes utilization and impact of the Transfers of Care Around Medicines (TCAM) service post-hospital discharge at community pharmacies. An increasing percentage of TCAM referrals were completed post-intervention, but 45% were not completed at all or took longer than one month. The impact of the TCAM service on adverse drug events (ADE) and unintentional medication discrepancies (UMD) was uncertain. Future research may explore reasons for low/late completions or focus on high-risk medications, as those were associated with the most ADE and UMD.
Ramjaun A, Hammond Mobilio M, Wright N, et al. Ann Surg. 2023;278:e1142-e1147.
Situational awareness is an essential component of teamwork. This qualitative study examined how situational awareness and team culture impact intraoperative handoff practice. Researchers found that participants often assumed that team members are interchangeable and that trained staff should be able to determine handoff appropriateness without having to consult the larger operating room team – both of these assumptions hinder team communication and situational awareness.
Vellonen M, Härkänen M, Välimäki T. J Clin Nurs. 2023;Epub Oct 6.
Ensuring medication safety in home care settings has unique challenges. In this study, researchers analyzed 1,027 incident reports involving medication errors and communication between home care and inpatient care settings. Four types of issues were identified – (1) information management such as incomplete medication lists or fragmentation of patient data, (2) cooperation between care team members, (3) work environment and lack of resources, and (4) individual-level factors, such as inadequate skills or human error.
Reale C, Ariosto DA, Weinger MB, et al. J Gen Intern Med. 2023;38:982-990.
Barcode mediation administration (BCMA) can reduce medication errors, but workarounds can hinder its effectiveness. Using simulations, this study explored potential medication-related errors associated with BCMA during an electronic health record (EHR) transition. The study was able to identify potential problems with both the old and new systems and provide performance data against which to benchmark future system and/or workflow changes.
Weeda ER, Ward R, Gebregziabher M, et al. Med Care. 2023;Epub Oct 4.
Fragmentation of care between inpatient and outpatient settings can lead to poor patient outcomes. Based on a cohort of veterans ages 65 years or older who had a myocardial infarction, this study examined the use of outpatient medications for secondary prevention (e.g., beta blockers, statins) in the preceding 30 days among patients treated at Veterans Health Administration (VA) versus non-VA hospitals. The researchers found that medication omissions, duplications and delays in prescribing of secondary prevention medications were more common among patients treated at non-VA hospitals.
McLoone M, McNamara M, Jennings MA, et al. J Hosp Med. 2023;18:994-998.
Healthcare workers can become desensitized to electronic safety alerts (alert fatigue) which can lead to errors and adverse events. Based on Safety II concepts such as organizational resilience and using in situ simulations of critical hypoxemic-event alarms in pediatric inpatient settings, this study identified four types of system resilience contributing to alarm resilience – secondary notification, team-based care, direct visualization of bedside monitors from outside patient rooms (or a central monitoring station) and presence at the bedside.
Kugler LJ, Kapeles MJ, Durrie DS. J Cataract Refract Surg. 2023;49:907-911.
Cataract surgery is a common ophthalmic procedure in the United States and is increasingly performed in office-based settings. This study assessed the rates of intra- or post-operative adverse events in three types of lens surgeries, including cataracts. Findings suggest similar or lower adverse event rates for office-based cataract or refractive lens surgery when compared to surgeries performed in ambulatory surgery centers or hospital operating rooms.
van Moll C, Egberts TCG, Wagner C, et al. J Patient Saf. 2023;19:573-579.
Diagnostic testing errors can contribute to delays in diagnosis and to serious patient harm. Researchers analyzed 327 voluntary incident reports from one medical center in the Netherlands and found that diagnostic testing errors most commonly occurred during the pre-analytic phase (77%), and were predominantly caused by human factors (59%). The researchers found that these diagnostic testing errors contributed to a potential diagnostic error in 60% of cases.
Gandhi TK, Schulson LB, Thomas AD. Jt Comm J Qual Patient Saf. 2023;Epub Sept 12.
Safety event reporting from both providers and patients is subject to bias. The authors of this commentary present several ways bias is introduced into reporting and offers strategies to ensure events are reported and analyzed in an equitable manner.
Wang B, Li D, Wang Y. J Contingencies Crisis Manag. 2023;Epub Oct 4.
Healthcare workers often must deliver care during complex situations. Using insights from safety science and political/social perspectives, the authors outline a new evidence-informed crisis learning framework. They use two sets of crisis event cases to describe how this framework can be used to examine the underlying causes and implications of the crises, which can inform strategies to promote safe patient care in the midst of complex, emergent situations.
Jala S, Fry M, Elliott R. J Clin Nurs. 2023;32:7076-7085.
Cognitive biases can impact the type of care a patient receives and their subsequent outcomes, particularly in the emergency department which operates under time and resource constraints. This review identified 18 studies on cognitive biases in emergency physicians and nurses. Most studies focused on implicit bias and on physicians. Of the five studies focused solely on nurses, all assessed bias in emergency department triage.
Lea W, Lawton R, Vincent CA, et al. J Patient Saf. 2023;19:553-563.
Organizational incident reporting allows for investigation of contributing factors and formation of improvement recommendations, but some recommendations are weak (e.g., staff training) and do not result in system change. This review found 4,579 recommendations from 11 studies, with less than 7% classified as "strong". There was little explanation for how the recommendations were generated or if they resulted in improvements in safety or quality of care. The authors contend additional research into how recommendations are generated and if they result in sustained improvement is needed.
Carvalho REFL de, Bates DW, Syrowatka A, et al. BMJ Open Qual. 2023;12:e002310.
Research has shown a robust safety culture improves patient outcomes, reduces length of hospital stay, and increases patient and staff satisfaction. As such, safety culture is increasingly being measured by healthcare organizations. This review sought to identify the factors measured by safety culture instruments in hospitals. The Hospital Survey on Patient Safety Culture and Safety Attitudes Questionnaire were the most frequently used instruments. Important factors include organizational, professional, and patient and family participation, although none of the instruments measured all three.
Foster M, MHA BS, Mazur L. BMJ Open Qual. 2023;12:e002284.
Healthcare leadership walkarounds (LWs) involve organizational leaders visiting hospital wards to hear directly from frontline staff about concerns and what is going well. This systematic review describes the impact of LWs on organizational and patient outcomes. Most studies (11 out of 12) measured organizational or clinical outcomes. Organizational outcomes included staff perception of safety culture, near miss reports, teamwork, and feeling heard. Only one study investigated the association between LWs and clinical outcomes; in that study, catheter-associated urinary tract infections decreased following implementation of LW.
Naya K, Aikawa G, Ouchi A, et al. PLoS One. 2023;18:e0292108.
Healthcare workers who are involved in patient safety incidents and experience adverse psychological or emotional outcomes are often referred to as second victims. This systematic review and meta-analysis found that 58% of healthcare workers in intensive care unit (ICU) settings have experienced second victim outcomes, including guilt, anxiety, anger at oneself, and decreased self-confidence. The review also found that one in five individuals took longer than 12 months to recover or did not recover at all, underscoring the importance of organizational support programs for healthcare workers involved in patient safety incidents.
Labrague LJ. Leadersh Health Serv (Bradf Engl). 2023;Epub Oct 9.
Leadership behaviors have an important impact on the workforce and work environment in both positive and negative ways. This review summarizes how toxic leadership impacts the nursing workforce and patient safety. Within the patient safety theme, toxic leadership was significantly associated with increased falls, nosocomial infections, and medication errors.
No results.
Newspaper/Magazine Article
Cohen JB. APSF Newsletter. 2023;38(10):93-95.
Zero harm, while a laudable goal, has been shown to have unintended consequences. This commentary calls for a morally neutral approach to human error, an elimination of blame in favor of a just culture, and harm reduction efforts that target the system instead of the individual.
Washington, DC: The Veterans Affairs Inspector General. October 4, 2023. Report No. 23-00080-227.
Wrong-site surgery and unintentionally retained surgical items are considered never events. This report details five wrong-site surgeries and three instances of retained surgical items at one VA medical center between 2018 and 2022. The findings suggest that timely investigation into events from 2018-2021 may have prevented three incidents in 2022. Additionally, the medical center failed to fully report the provider responsible for three of the wrong-site surgeries.
Special or Theme Issue
BMJ 2023(383):2219, 2278, 2319, 2331.
This compendium of editorials and opinion pieces discuss “Martha’s Rule,” a new policy in the United Kingdom motivated by the death of a pediatric patient to sepsis and the systemic weaknesses contributing to the adverse outcome. The policy is intended to encourage patients and caregivers to request a second opinion if a patient’s health condition is deteriorating and they feel their concerns are not being taken seriously by the healthcare team. The articles discuss the importance effective communication between clinicians, caregivers, and patients, mitigating adverse impacts of hierarchies, and the role of patient and caregiver engagement in the design of safe healthcare systems.
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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