Email Updates
November 8, 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
Garzón González G, Alonso Safont T, Conejos Míquel D, et al. J Patient Saf. 2023;19:508-516.
Retrospective chart review is the standard for estimating prevalence of adverse events manual review of the electronic health record (EHR) is resource intensive. This study describes the construction and validation of electronic trigger set, TriggerPrim, to rapidly identify charts with potential adverse events in primary care. The resulting set has five triggers: ≥3 appointments in a week at the PC center, hospital admission, hospital emergency department visit, prescription of major opioids, and chronic benzodiazepine treatment in patients 75 years or older. Use of TriggerPrim reduced time in the EHR by half.
Huynh J, Alim SA, Chan DC, et al. Ann Intern Med. 2023;Epub Oct 14.
Access to primary care is becoming more challenging, in part due to physicians leaving the field. Twenty-nine states have expanded nurse practitioner (NP) autonomy to increase access. This study compares potentially inappropriate prescribing practices between NPs and primary care physicians (PCP). In the study population, adults aged 65 and older, NPs and PCPs had nearly identical rates of potentially inappropriate prescribing. The authors encourage focusing on improving prescribing practices among all prescribers instead of working to limit prescribing to physicians.
Mohamed I, Hom GL, Jiang S, et al. Acad Radiol. 2023;Epub Sep 22.
Psychological safety is an important principle in identifying problems and improving patient outcomes. This narrative review highlights five best practices to foster psychological safety in radiology residencies – (1) establish clear goals and educational strategies, (2) build a formal mentoring program, (3) assess psychological safety, (4) advocate for radiologists as educators, and (5) support non-radiology staff. Although the review focuses on radiology residency programs, these strategies can be adapted to any residency program.
Book/Report
Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-0082.
The sharing of data is a core element of a learning health system. AHRQ has released the Network of Patient Safety Databases (NPSD) Chartbook 2023, which offers an overview of nonidentifiable, aggregated patient safety event and near-miss information, voluntarily reported by AHRQ-listed Patient Safety Organizations across the country between June 2014 and December 2022. The chartbook outlines the extent of harm reported, distribution of patient safety events, near misses, and unsafe conditions.
Gallois JB, Zagory JA, Barkemeyer B, et al. Pediatr Qual Saf. 2023;8:e695.
Structured handoff tools can improve situational awareness and patient safety. This study describes the development and implementation of a bespoke tool for handoffs from the operating room to the neonatal intensive care unit (NICU). While use remained inconsistent during the study period, the goal of 80% compliance was achieved and 83% surveyed staff agreed or strongly agreed that the handoff provided needed information, up from 21% before implementation.
Milic V, Cameron L, Jones C. Br J Nurs. 2023;32:840-848.
Double checking of medication administration one strategy meant to reduce medication errors. In this study, 29 critical care nurses took part in a focus group exploring the barriers to double-checking during medication administration. Participants discussed several challenges, such as patient location (particularly for patients in isolation due to infection control measure), health IT limitations, and unclear roles and responsibilities.
Baker DL, Giuliano KK, Desmarais M, et al. Infect Control Hosp Epidemiol. 2023;Epub Oct 25.
Hospital-acquired pneumonia (HAP) is one of the most common healthcare-associated infections in the United States. In this case-control retrospective study of Medicare beneficiaries, patients with HAP were 2.8 times more likely to die than patients without HAP. Length of stay and overall cost were also significantly higher in the HAP group. The authors suggest quality improvement efforts like the Keystone ICU project could decrease HAP rates, saving lives and money.
Huynh J, Alim SA, Chan DC, et al. Ann Intern Med. 2023;Epub Oct 14.
Access to primary care is becoming more challenging, in part due to physicians leaving the field. Twenty-nine states have expanded nurse practitioner (NP) autonomy to increase access. This study compares potentially inappropriate prescribing practices between NPs and primary care physicians (PCP). In the study population, adults aged 65 and older, NPs and PCPs had nearly identical rates of potentially inappropriate prescribing. The authors encourage focusing on improving prescribing practices among all prescribers instead of working to limit prescribing to physicians.
Seaman K, Meulenbroeks I, Nguyen A, et al. Int J Qual Health Care. 2023;35:mza080.
Patients in long-term or residential care facilities are at high risk of falls. In this study, researchers applied the International Classification for Patient Safety (ICPS) criteria to categorize types of falls occurring in residential aged care facilities in Australia. Falls requiring hospitalization more often occurred in residents’ bedrooms or communal areas. Resident pre-existing psychological or physical health were the most common contributing factor in falls that required a hospitalization.
Bagot KL, McInnes E, Mannion R, et al. BMC Health Serv Res. 2023;23:1012.
Unprofessional behavior can have a detrimental effect on coworkers, culture, and patient safety. This qualitative study presents perspectives of middle managers in hospitals that implemented a program allowing and encouraging workers to report unprofessional, as well as positive, behavior. Themes included staying silent but active (e.g., avoiding the unprofessional colleague), history and hierarchy, and double-edged swords (e.g., pros and cons of anonymous reporting).
Lowe JT, Leonard J, Dominguez F, et al. Diagnosis (Berl). 2023;Epub Oct 6.
Non-English primary language (NEPL) patients may encounter barriers navigating the healthcare system and communicating with providers. In this retrospective study, researchers used the Safer Dx tool to explore differences in diagnostic errors among NEPL versus English-proficient (EP) patients. Among 172 patients who experienced a diagnostic error, the proportion was similar among EP and NEPL groups and NEPL did not predict higher odds of diagnostic error.
Barlow M, Watson B, Morse K, et al. J Health Organ Manag. 2023;Epub Sep 26.
Hierarchy and expected response may inhibit someone from speaking up about a safety concern. This study used two vignettes of a speaking up situation with randomization on speaker seniority, discipline (i.e., allied staff, nurse, physician), tone (i.e., accommodating or non-accommodating), and the presence of other people in the room. All participants were more likely to respond positively to the accommodating tone, but the impact of seniority varied by receiver's discipline.
Nitsche E, Dreßler J, Henschler R. J Blood Med. 2023;14:435-443.
Transfusion errors can lead to serious patient harm. In this retrospective analysis of transfusion medical records and related documentation, researchers examined transfusion incident characteristics and logistical errors associated with incidents. Common logistical errors included elevated hemoglobin, inadequate bedside tests, inadequate patient identification, and laboratory errors.
Pelikan M, Finney RE, Jacob A. AANA J. 2023;91(5):371-379.
Providers involved in patient safety incidents can experience adverse psychological and physiological outcomes, also referred to as second victim experiences (SVE). This study used the Second Victim Experience and Support Tool (SVEST) to evaluate the impact of a peer support program on anesthesia providers’ SVE. Two years after program implementation, reported psychological distress decreased and over 80% of participants expressed favorable views of the program and its impact on safety culture.
Garzón González G, Alonso Safont T, Conejos Míquel D, et al. J Patient Saf. 2023;19:508-516.
Retrospective chart review is the standard for estimating prevalence of adverse events manual review of the electronic health record (EHR) is resource intensive. This study describes the construction and validation of electronic trigger set, TriggerPrim, to rapidly identify charts with potential adverse events in primary care. The resulting set has five triggers: ≥3 appointments in a week at the PC center, hospital admission, hospital emergency department visit, prescription of major opioids, and chronic benzodiazepine treatment in patients 75 years or older. Use of TriggerPrim reduced time in the EHR by half.
Sentinel Event Alerts
Jt Comm J Qual Patient Saf. 2023;Epub Oct 18.
Surgical fires are a rare yet potentially harmful event for both patients and care teams. The alert provides reduction guidance for organizations to mitigate conditions that enable surgical fires and suggests tactics to improve communication as a primary strategy for preventing this potentially catastrophic accident in operating rooms.
Clarke-Romain B. Emerg Nurse. 2023;Epub Sep 19.
Delays in raising concerns in acute or emergency care can have tragic consequences. This commentary uses a case study to highlight barriers to speaking up and evidence-based tools nurses can use such as the CUS Tool and two-challenge rule. Training all healthcare staff in communication techniques can encourage speaking up and respectful responses.
Kavanagh KT, Cormier LE. Medicine (Baltimore). 2023;102:e35095.
Primary care plays an important role in identifying, avoiding and mitigating patient safety issues. This report highlights several patient safety priorities and how small (<10 providers) primary care practices can promote safe practice and outcomes for their patients.
Mohamed I, Hom GL, Jiang S, et al. Acad Radiol. 2023;Epub Sep 22.
Psychological safety is an important principle in identifying problems and improving patient outcomes. This narrative review highlights five best practices to foster psychological safety in radiology residencies – (1) establish clear goals and educational strategies, (2) build a formal mentoring program, (3) assess psychological safety, (4) advocate for radiologists as educators, and (5) support non-radiology staff. Although the review focuses on radiology residency programs, these strategies can be adapted to any residency program.
Grace MA, O'Malley R. Simul Healthc. . 2023;Epub Sep 19.
In situ simulation can reveal latent safety threats before they cause harm. This review identified 15 studies of in situ simulations conducted in the emergency department including simulations conducted prior to opening new facilities and to address emerging COVID-19 concerns. The most commonly identified safety threats were related to equipment and team communication.
No results.
Multi-use Website
United States Office of the Inspector General: 2010-2023.
Large-scale data analysis provides insights to generate evidence-based improvement action. This collection of reports provides access to investigations of the impact of healthcare-related harm events in Department of Health and Human Services (HHS) programs and across the United States health system. This set of publications not only examines weaknesses but provides recommendations for improvement on topics such as gaps in fall reporting by home health agencies, Medicare adverse events and the viability of payment incentives as a strategy for medical harm reduction.
Newspaper/Magazine Article
Jewett C. New York Times. October 30, 2023
US Food and Drug Administration regulation and review is noted as having gaps in process that can affect patient safety. This article discusses reasons for the reluctance of physicians to fully embrace the use of artificial intelligence tools approved by the FDA in their practice. The concerns include lax regulation, poor product development transparency and lack of robust real-world accuracy data.
Newspaper/Magazine Article
Twenter P. Becker's Clinical Leadership. October 30, 2023.
Health care has long held commercial aviation as a beacon to guide patient safety improvement work. This article examines how well aviation safety mechanisms map to medical care safety efforts such as checklists, just culture and operating room black boxes.
Maxwell A. Washington DC: Office of Inspector General; September 2023. Report no. OEI-05-22-00290.
Falls are a persistent threat to patient safety and effective reporting of this adverse event can assist in understanding important gaps in care. This report examines the incidence of Medicare home health patients experiencing falls with major injury resulting in hospitalization that were not reported as required. 55% of falls were not documented thusly negatively impacting the viability of Care Compare as a reliable public resource for this information.
Book/Report
Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-0082.
The sharing of data is a core element of a learning health system. AHRQ has released the Network of Patient Safety Databases (NPSD) Chartbook 2023, which offers an overview of nonidentifiable, aggregated patient safety event and near-miss information, voluntarily reported by AHRQ-listed Patient Safety Organizations across the country between June 2014 and December 2022. The chartbook outlines the extent of harm reported, distribution of patient safety events, near misses, and unsafe conditions.
Newspaper/Magazine Article
Le Coz E. USA Today. October 26, 2023.
Chain pharmacies provide prescriptions in an environment that facilitates error due to production pressures, poor error reporting, and a lack of safety culture. This feature story examines working conditions at primary retail pharmacies in the United States and draws from staff experiences, industry data and frontline evidence to illustrate the problem as a threat to patient safety.
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.
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