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December 13, 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
Benhamou D, Weiss M, Borms M, et al. Ann Pharmacother. 2023;Epub Nov 28.
Pre-filled syringes ordered directly from the manufacturer can improve medication administration safety. This review evaluated medication errors, wastage, time savings, and contamination in pre-filled syringes. There were no differences in rates of contamination between pre-filled and conventionally prepared medication, but the remaining three outcomes in pre-filled syringes all showed improvements.
Bodek A, Pommée M, Berger A, et al. BMC Prim Care. 2023;24:251.
Critical incident reporting is common in inpatient settings, but not always as robust in ambulatory or outpatient care. This study sought to understand how outpatient providers (i.e., primary care, dentists, dermatology, orthopedic surgery, psychiatry/psychology) define critical incidents and how they are handled in their offices. Respondents described critical incidents across a spectrum, from organizational processes to medical emergencies. Many did not have formal reporting or quality improvement systems in place. The authors emphasize the importance of including safety culture and critical incident reporting in medical training.
Chen VW, Chidi AP, Dong Y, et al. JAMA Surg. 2023;158:1176.
Identifying patterns of adverse events in real time can prevent avoidable patient harm. This study used six years of data from the Veterans Affairs Surgical Quality Improvement Program to identify hospitals with excess risk-adjusted 30-day perioperative mortality rates. Results show excess perioperative mortality can be detected a median of 49 days before traditional end-of-quarter reporting, suggesting more frequent data collection can reduce perioperative mortality.
Cooper WO, Foster JJ, Hickson GB, et al. Jt Comm J Qual Patient Saf. 2023;49:671-679.
Policies for dealing with unprofessional behavior are widespread but may lack specific processes for allegations of sexual misconduct. This study aimed to assist healthcare organizations to appropriately triage and respond to allegations of sexual boundary violations. Essential components of the organization's response include leadership engagement; coordinated responses; clear articulation of values, policies, and procedures; aligned data reporting; thoughtful reviews; and securing appropriate resources.
Schroeck H, Whitty MA, Martinez-Camblor P, et al. Br J Anaesth. 2023;131:598-606.
Non-standard work environments may present challenges to provider well-being and patient safety. This study evaluated perceptions of workload, anxiety and stress among anesthesia providers working in standard operating rooms (ORs) compared to remote hybrid rooms with intraoperative MRI (MRI-OR). Findings indicate that providers working in MRI-ORs report lower perceived safety and higher levels of workload, anxiety, and stress compared to standard OR providers.
Bodek A, Pommée M, Berger A, et al. BMC Prim Care. 2023;24:251.
Critical incident reporting is common in inpatient settings, but not always as robust in ambulatory or outpatient care. This study sought to understand how outpatient providers (i.e., primary care, dentists, dermatology, orthopedic surgery, psychiatry/psychology) define critical incidents and how they are handled in their offices. Respondents described critical incidents across a spectrum, from organizational processes to medical emergencies. Many did not have formal reporting or quality improvement systems in place. The authors emphasize the importance of including safety culture and critical incident reporting in medical training.
Dave N, Sjöholm D, Hedberg P, et al. JAMA Netw Open. 2023;6:e2341936.
Hospital-acquired COVID-19 was a major concern, particularly during the early phases of the pandemic when population immunity was low. This study includes nearly 304,000 patients in Sweden, divided into two timeframes within the pandemic. Nosocomial infection rates were low across both time frames, but 30-day mortality was higher (compared to patients without infection) in the first timeframe when immunity was low. During the second timeframe when vaccination levels were higher, there was no difference in 30-day mortality rates between patients with or without nosocomial infections.
Conroy SA, Vogus TJ. Health Care Manage Rev. 2023;49:68-73.
Becoming a high reliability organization remains challenging due to the many contributing factors involved. This study linked unit-level nurse pay to high reliability characteristics of information sharing and safety organizing. Higher minimum pay, higher average pay, and lower pay dispersion are positively associated with information sharing and safety organizing.
Chen VW, Chidi AP, Dong Y, et al. JAMA Surg. 2023;158:1176.
Identifying patterns of adverse events in real time can prevent avoidable patient harm. This study used six years of data from the Veterans Affairs Surgical Quality Improvement Program to identify hospitals with excess risk-adjusted 30-day perioperative mortality rates. Results show excess perioperative mortality can be detected a median of 49 days before traditional end-of-quarter reporting, suggesting more frequent data collection can reduce perioperative mortality.
Jacobson JO, Zerillo JA, Doolin J, et al. J Patient Saf. 2023;19:580-586.
Oncology is a high-risk care environment involving complex medication administration. In this study, researchers applied a previously validated taxonomy to identify and characterize medical oncology-related incidents at three cancer centers between January 2019 and December 2020. The majority of incidents involved four types of errors – prescriber ordering (22%), nursing care (15%), pharmacy (14%), and communication issues (15%). Nearly 45% of incidents reached the patient without causing harm, but 8.4% resulted in patient harm. The researchers identified nine intermediate- and high-risk scenarios carrying the greatest risk to patient safety, including infusion pump programming errors, patient identification errors, and treatment/scheduling errors.
Hibbert PD, Ash R, Molloy CJ, et al. Int J Qual Health Care. 2023;35:mzad085.
Safety hazards in long-term care or residential care environments can threaten patient safety. This analysis of 65 accreditation assessments for long-term care facilities in Australia identified 2,267 patient safety incidents between September 2020 and March 2021. Nearly 50% of incidents involved clinical processes or procedures, and 25% involved documentation errors. The authors note that accreditation reports can be effectively used as a source to prioritize and inform patient safety improvement efforts.
Bavli I. J Law Med Ethics. 2023;51:385-402.
Public health errors, whether by action or inaction, contribute to distrust of public health officials and policy makers. Through examples of the opioid crisis in the United States and Canada, and radiation therapy in Canada, this article proposes a new definition of public health errors and asserts that these errors should be classified as errors of omission or commission, and as culpable or non-culpable. Regardless of type, all errors must be responded to promptly and transparently, with dedicated strategies to communicate with marginalized populations.
Copeland S, Hinrichs-Krapels S, Fecondo F, et al. BMC Health Serv Res. 2023;23:1297.
Global health challenges and local environmental disasters have prompted an increase of research into the resilience of healthcare systems and organizations. This analysis identified 80 studies and 30 reviews of healthcare resilience from 2004 through June 2021. Unsurprisingly, COVID-19 dominated the research from 2020-2021. Most publications focused on health systems or hospitals, with substantially less attention shown to community-based or primary care.
Benhamou D, Weiss M, Borms M, et al. Ann Pharmacother. 2023;Epub Nov 28.
Pre-filled syringes ordered directly from the manufacturer can improve medication administration safety. This review evaluated medication errors, wastage, time savings, and contamination in pre-filled syringes. There were no differences in rates of contamination between pre-filled and conventionally prepared medication, but the remaining three outcomes in pre-filled syringes all showed improvements.
Unger MD, Barr JN, Brower JA, et al. BMC Complementary Medicine and Therapies. 2023;23:407.
Complementary and alternative medicine present unique patient safety challenges. In this analysis of 23 studies evaluating osteopathic manipulative treatment (OMT), researchers estimate the incidence of adverse events at 1.0 per 100 post-OMT interval-days, with the majority being mild in terms of severity.
Rickey L, Auger K, Britto MT, et al. Pediatrics. 2023;152:e2023061281.
Children are at increased risk for medication errors. This scoping review explored the use of measures to capture pediatric medication errors in ambulatory care. The authors identified 142 studies evaluating 21 measures of medication errors, including measures of medication prescribing errors and home administration errors. Only 31 studies assessed measure reliability.
McGowan JE, Attal B, Kuhn I, et al. BMJ Qual Saf. 2023;Epub Nov 29.
Effective implementation of patient safety programs can be challenging. This scoping review evaluated 15 large-scale quality improvement programs focused on intrapartum care in the United Kingdom’s National Health Service. The authors identified poor reporting of evidence base supporting the interventions, limited descriptions of implementation support, and explicit use of existing patient engagement strategies or frameworks to guide implementation.
International Meeting/Conference
Alliance for Innovation on Maternal Health. January 10-April 10, 2024.
Maternal safety strategies are being developed to infuse improvements across the sector. This monthly webinar series will engage practitioners to adapt, adopt, and implement an established set of best practices and enhance the reliability of maternal care.
Newspaper/Magazine Article
DeGuzman C. KFF Health News. December 5, 2023
Racial and ethnic bias permeates medical interactions to detract from safe and effective care. This article discusses the stereotypical assessments made by practitioners that affect diagnosis, communication, and treatment suggestions, and thus the willingness of minoritized group patients to seek care.
Organizational Policy/Guidelines
Smyrna, GA: Patients for Patient Safety US; December 1, 2023.
Effective measurement has been a long-standing challenge across patient safety efforts to generate data useful across environments to gain overarching understanding of problems and areas to target for improvement. This document outlines a multi-domain series of draft structural measures for use in Centers for Medicare & Medicaid Services (CMS) programs to identify the robustness of organizational factors such as leadership commitment and patient engagement to support safety improvement. Comments can be submitted until December 22, 2023.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute Care. 2023;28(24):1-3.
The inability to understand health terminology is a recognized barrier to safe patient care. This article describes the impact of low personal health literacy on medication safety. Improvement strategies discussed include patient education, practitioner coaching and interpreter services.
Newspaper/Magazine Article
O'Neill E. Health Shots. National Public Radio. December 2, 2023.
Inordinate focus on one element of a situation can reduce the capacity to successfully complete tasks and make decisions. This article discusses how clinician emphasis on patient weight can distract from effective care decisions, discussions, and relationships, resulting in care delay and misdiagnosis.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Rachel Ann Hight, MD, FACS |
This case describes a 55-year-old woman who sustained critical injuries after a motor vehicle crash and had a lengthy hospitalization. On hospital day 30, a surgeon placed a percutaneous endoscopic gastrostomy (PEG) tube in the intensive care unit (ICU) after computed tomography (CT) scan showed no interposed bowel between the stomach and the anterior abdominal wall. After the uncomplicated PEG placement, the surgeon cleared the patient’s team to advance tube feeds as tolerated. After several weeks of poorly tolerated tube feedings, the interventional radiology team reviewed a CT scan which had been obtained by another service 6 days after the PEG was placed and noted (for the first time) that the gastrostomy tube traversed the liver. Insufficient communication and fragmented care coordination across care settings contributed to poor management of the malpositioned PEG tube. The commentary underscores the importance of clear documentation of complications, highlights best practices to mitigate risks during patient care transition, and the importance of using multiple communication approaches to ensure appropriate continuity of care.
WebM&M Cases
Christian Bohringer, MBBS, and Sharon Ashley, MD |
A 38-year-old woman with class 3 obesity required removed of a gastric balloon under general anesthesia. She required a relatively large dose of rocuronium for endotracheal intubation, and she was given intravenous sugammadex (200 mg) at the end of the procedure to reverse the neuromuscular block. A quantitative neuromuscular block monitor was not used, but reliance was placed on clinical signs. Shortly after arrival in the post-anesthesia care unit, she couldn’t move or open her eyes and became jittery with low oxygen saturation. Quantitative blockade monitoring revealed a “train of four” (TOF) ratio less than 70%, so she was given another 200 mg of intravenous sugammadex with return of normal motor function.
WebM&M Cases
Luciano Sanchez, PharmD and Patrick Romano, MD, MPH |
An 81-year-old man was admitted to the intensive care unit (ICU) with a gastrointestinal bleed and referred for a diagnostic colonoscopy. The nurse preparing the patient for the colonoscopy mistakenly selected a jug of dialysis liquid rather than a polyethylene glycol solution commonly used to clean the colon for colonoscopy. When the barcode on the jug of dialysis liquid did not scan, the nurse called the hospital pharmacy for assistance and was provided a new barcode via a tube system. After the patient had difficulty drinking the solution, the nurse gave the rest of the liquid through a feeding tube bag. The medication mix-up was identified around midnight and the patient died about 7 hours later.
This Month’s Perspectives
Interview
Joan Stanley, PhD, NP, FAAN, FAANP |
Joan Stanley is the chief academic officer at the American Association of Colleges of Nursing (AACN). We spoke to her about how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.
Perspectives on Safety
Joan Stanley, PhD, NP, FAAN, FAANP; Bryan M. Gale, MA; Sarah E. Mossburg, RN, PhD |
This piece discusses how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.
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