Email Updates
November 1, 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
Beaulieu-Jones BR, Wilson S, Howard DS, et al. JAMA Surg. 2023;Epub Oct 18.
Morbidity and Mortality Conferences (MMC) have a long history in medical education and error analysis. This review summarizes MMC best practices to optimize format and design to advance trainee education and format. Four overarching themes emerged, including formal preparation in advance of the MMC, a balance of presentation and discussion, formal channels for quality improvement and education, and an emphasis on safety culture.
Koehl JL. Clin Geriatr Med. 2023;39:635-645.
Older adults are at increased risk of medication errors due to medical complexity and polypharmacy. This article discusses medication safety and adverse drug events specific to a geriatric population and highlights prescribing and deprescribing tools that can contribute to safer prescribing practices.
Pogorzelska-Maziarz M, de Cordova PB, Manning ML, et al. Am J Infect Control. 2023;Epub Aug 23.
The COVID-19 pandemic highlighted systemic weaknesses in the healthcare system. This survey of 3,067 registered nurses working in New Jersey used the Donabedian framework to identify challenges related to providing safe care during the pandemic. Respondents identified several organizational factors, including inadequate resources and staffing, which adversely impacted their ability to adhere to patient safety and infection prevention and control protocols during the pandemic.
Kim J, Cai ZR, Chen ML, et al. JAMA Netw Open. 2023;6:e2338050.
Artificial intelligence (AI) is increasingly used in healthcare, but concerns have been raised that it can exacerbate existing disparities because of underlying biases in AI tools. In this observational study, researchers evaluated biases in clinician versus AI chatbox responses to 19 clinical vignettes involving cardiology, emergency medicine, rheumatology, and dermatology. Findings indicate that both AI chatboxes and clinicians provide different clinical recommendations based on a patient’s gender, race/ethnicity, and socioeconomic status under certain clinical scenarios.
Terwilliger IA, Johnson JK, Manojlovich M, et al. Jt Comm J Qual Patient Saf. 2023;Epub Sep 4.
Quality improvement and patient safety initiatives are difficult to implement and sustain. This commentary describes factors that contributed to successful implementation of the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study. Consistent with other research, important factors included leadership involvement, goal alignment, site leader commitment, and nurse/physician agreement that improvement was needed. The authors suggest hospital leaders consider these contextual factors prior to implementing similar improvement projects.
Cicero MX, Baird J, Brown L, et al. Prehosp Emerg Care. 2023;Epub Sep 12.
The pediatric population faces unique challenges in the prehospital setting. This prospective chart review study classified adverse safety events (ASE) of pediatric patients at 15 emergency medical services (EMS) agencies. More than 20% of encounters contained at least one ASE, although most were unlikely to cause harm (e.g., missed documentation).
Kalenderian E, Bangar S, Yansane A, et al. J Patient Saf. 2023;19:305-312.
Understanding factors that contribute to adverse events (AE) is key to preventing them from recurring. This study used an electronic trigger tool to identify potential AE in two dental practices. Of 439 charts reviewed, 13% contained at least one AE. The most common AE was post-procedural pain; the expert panel reported 21% of those AEs were preventable. Person-related factors (e.g., supervision, fatigue) were the most common contributing factors.
Grailey K, Hussain R, Wylleman E, et al. BMC Nurs. 2023;22:378.
Barcode medication administration (BCMA) technology reduces risk of many types of medication errors (e.g., wrong drug, wrong patient, omission). This qualitative study of nurses in low- and high-BCMA-use hospital wards describes barriers and facilitators to use. Barriers were consistent across use levels, suggesting that team culture and accountability play a crucial role in increasing BCMA use.
Gifford A, Butcher B, Chima RS, et al. J Hosp Med. 2023;Epub Oct 4.
Shared situation awareness is shown to improve patient outcomes in the pediatric intensive care unit (PICU). This article outlines the process of designing communication and signage tools to maintain or improve situational awareness in anticipation of moving to a new clinical space. With the new tools in place in the new PICU, shared situation awareness for residents, nurses, and respiratory therapists improved.
Pogorzelska-Maziarz M, de Cordova PB, Manning ML, et al. Am J Infect Control. 2023;Epub Aug 23.
The COVID-19 pandemic highlighted systemic weaknesses in the healthcare system. This survey of 3,067 registered nurses working in New Jersey used the Donabedian framework to identify challenges related to providing safe care during the pandemic. Respondents identified several organizational factors, including inadequate resources and staffing, which adversely impacted their ability to adhere to patient safety and infection prevention and control protocols during the pandemic.
Koehl JL. Clin Geriatr Med. 2023;39:635-645.
Older adults are at increased risk of medication errors due to medical complexity and polypharmacy. This article discusses medication safety and adverse drug events specific to a geriatric population and highlights prescribing and deprescribing tools that can contribute to safer prescribing practices.
Dorimain M-V, Plouffe-Malette M, Paquette M, et al. BMJ Open Qual. 2023;12:e002291.
Laboratory tests are an integral part of diagnosing illness and injury, but system issues can result in the delayed communication of results to patients. This article describes use of the AHRQ toolkit Improving Your Office Testing Process to implement new testing and communication procedures. As an academic family practice clinic, an important first step was allowing residents to order tests and receive results in their own name instead of through an attending physician, which can cause delays in communication to patients. Providers and patients were satisfied with the new process.
Ali KJ, Goeschel CA, DeLia DM, et al. Diagnosis (Berl). 2023;Epub Oct 5.
To improve patient safety, payers such as the Centers for Medicare & Medicaid have implemented policies that limit reimbursement for certain healthcare-associated harms. This commentary introduces the “Payer Relationships for Improving Diagnoses (PRIDx)” framework describing how payers may implement similar policies to reduce diagnostic errors.
Bremner BT, Heneghan CJ, Aronson JK, et al. J Patient Saf Risk Manag. 2023;28:227-236.
Autopsies and coronial investigations provide important learning opportunities. In the UK, coroners may issue Prevention of Future Death reports (PFD) when they determine taking actions could prevent future deaths. This review summarizes studies that use PFDs to investigate patient safety, such as medication- or diagnosis-related deaths. The authors conclude the impact of PFDs could be strengthened by improving the reporting and dissemination system and enforcing the requirement that hospitals submit a response.
Sutcliffe KM. Anesthesiol Clin. 2023;41:707-717.
Achieving high reliability remains difficult for many organizations. This article provides a brief history of the concept of high reliability organizations (HROs) and key features of high reliability culture, such as fostering trust and respect among teams and creating systems and processes to elicit feedback/reflections and identify opportunities for improvement. The authors discuss these concepts in the setting of anesthesiology and perioperative care.
Beaulieu-Jones BR, Wilson S, Howard DS, et al. JAMA Surg. 2023;Epub Oct 18.
Morbidity and Mortality Conferences (MMC) have a long history in medical education and error analysis. This review summarizes MMC best practices to optimize format and design to advance trainee education and format. Four overarching themes emerged, including formal preparation in advance of the MMC, a balance of presentation and discussion, formal channels for quality improvement and education, and an emphasis on safety culture.
Roy JM, Rumalla K, Skandalakis GP, et al. Neurosurg Rev. 2023;46:227.
Failure to rescue (FTR) quality metrics measure the ability of healthcare teams and hospitals to prevent mortality following a major complication. This systematic review included 12 studies and examined how FTR has been used in neurosurgical populations. The authors discuss several modifications to existing FTR definitions to better suit neurosurgical patients, such as incorporating measures of baseline frailty.
Zaij S, Pereira Maia K, Leguelinel-Blache G, et al. BMC Health Serv Res. 2023;23:927.
An increasing strategy to reduce adverse drug events (ADE) is pharmacist medication review, typically involving other members of the care team. This qualitative review summarizes randomized studies of interventions with multidisciplinary care teams to reduce ADE. Most interventions were time-intensive (1- to 2-hours), including four steps (data collection, appraisal report, multidisciplinary medication review, follow up). Most teams consisted of a pharmacist, physician, and nurse, although some included other providers such as psychologists or social workers.
No results.
Special or Theme Issue
McEvoy MD, Abernathy JH, 3rd. Anesthesiol Clin. 2023;41(4):xvii-xix;693-886.
Organizational, unit, and team culture affect the safety of surgical care. This special issue examines overarching principles, common practices, and practical actions that support safe perioperative processes and settings. Topics discussed include team dynamics, operating room design, and high reliability.
Gilbert R, Asselbergs M, Davis D, et al. Healthcare Excellence Canada; 2023.
Patient safety requires a systems approach to identify problems and arrive at lasting solutions that reduce harm. This document encourages discussion amongst a broad base of stakeholders to address all forms of harm, such as discrimination, inequality, and psychological stress, in addition to physical injury. The resource insists these components be incorporated in work to close quality and safety gaps across the health care system.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute care edition. October 19, 2023;28(21):1-4.
Process disconnects can cause administration mistakes that lead to harm. This article discusses reasons for holding medications and how workflow issues can contribute to medication temporary stop order problems. Recommendations for improvement include examining electronic health record alerts, assigning one prescriber to oversee medication reconciliation, and instituting a policy on hold orders.
Newspaper/Magazine Article
Noguchi Y. Health Shots and All Things Considered. National Public Radio. October 23, 2023.
Drug shortages, while often discussed as a system failure, demonstrate harm at an individual level. This story highlights the work of a patient activist who was inspired by the threat to her daughter’s care posed by a lack of chemotherapy availability, to provide needed medications during system disruptions to keep patients safe.
This Month’s WebM&Ms
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.
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
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.
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!
