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January 10, 2024 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

Havranek MM, Rüter F, Bilger S, et al. Int J Qual Health Care. 2023;35.
The AHRQ Patient Safety Indicators (PSIs) are used to identify patient safety events in acute care settings using administrative data. This retrospective study examined the performance of 16 PSIs across nine hospitals in Switzerland (where the indicators had not been previously applied). The authors attributed low positive predictive value (PPV) in three of the PSIs (pressure injury, falls, and perioperative embolism/thrombosis) to lack of present-on-admission (POA) information, whereas performance of several other indicators were not influenced by missing POA flags.
Jabbour S, Fouhey D, Shepard S, et al. JAMA. 2023;330:2275.
Artificial intelligence (AI) is increasingly used in healthcare to support the diagnostic process, but concerns remain about the potential for error and bias. In this study, clinicians working at hospitals across 13 states were randomized to view a series of six AI diagnostic predictions with or without explanations and asked to determine the likelihood of whether the patient’s acute respiratory failure was attributable to pneumonia, heart failure, or chronic obstructive pulmonary disease (COPD). Each series of clinical vignettes also included three systematically biased vignettes. Clinicians’ baseline diagnostic accuracy for the three diagnoses was 73%; AI models with and without explanations improved diagnostic accuracy, but systematically biased models had a larger, adverse impact on diagnostic accuracy.
Kannan S, Bruch JD, Song Z. JAMA. 2023;330:2365-2375.
Changes in hospital leadership and ownership can impact patient safety and health outcomes. This study compared hospital-acquired adverse events among Medicare patients treated at private equity-acquired hospitals versus matched controls over a ten-year period. Researchers found that Medicare patients experienced a 25% increase in hospital-acquired conditions when treated at private equity hospitals. Findings indicate a significant increase in in-hospital falls and healthcare-associated infections (i.e., central-line associated blood stream infections, surgical site infections) despite private equity hospitals placing fewer central lines overall and having lower surgical volume. There was no change in 30-day mortality after hospital discharge, but in-hospital mortality decreased slightly at private equity versus control hospitals.
Giuffrida P, Davila S. Nursing. 2024;54:35-40.
Nurse burnout and overwork are recognized motivators for nurse turnover. This article describes how applying Maslow's hierarchy of needs to healthcare can increase nurse retention and reduce burnout. Interventions include ensuring staff receive competitive compensation, work to the top of their license, and have opportunities for continuing professional development.
Doolin JW, Schaffer AC, Tishler RB, et al. J Healthc Risk Manag. 2024;43:18-28.
Closed malpractice claims are frequently analyzed to identify serious patient safety threats. This study used malpractice claims against medical oncologists to identify areas for practice and education improvement. Provider cognitive error, medication adverse events, and inadequate communication between providers were the most frequent contributing factors to patient harm.
Kannan S, Bruch JD, Song Z. JAMA. 2023;330:2365-2375.
Changes in hospital leadership and ownership can impact patient safety and health outcomes. This study compared hospital-acquired adverse events among Medicare patients treated at private equity-acquired hospitals versus matched controls over a ten-year period. Researchers found that Medicare patients experienced a 25% increase in hospital-acquired conditions when treated at private equity hospitals. Findings indicate a significant increase in in-hospital falls and healthcare-associated infections (i.e., central-line associated blood stream infections, surgical site infections) despite private equity hospitals placing fewer central lines overall and having lower surgical volume. There was no change in 30-day mortality after hospital discharge, but in-hospital mortality decreased slightly at private equity versus control hospitals.
Goldman BI, Bharadwaj R, Fuller M, et al. Diagnosis (Berl). 2023;10:375-382.
Autopsies are integral to detection of major diagnostic errors (DE). In this study, 852 autopsies containing one or more DE were investigated for potential gender and/or racial bias. From 2012-2015, DE rates were higher for women compared to men, but no significant effect of race was observed. From 2015-2019, however, there were no significant differences by gender, but patients identified as non-white showed higher rates of DE.  
Carr MM, Foreman AM, Friedel JE, et al. J Patient Saf. 2024;20:16-21.
Accreditation Council for Graduate Medical Education (ACGME) resident work hour restrictions have shown mixed results, are controversial and may not be fully complied with. This study assessed which factors influence residents to take a post-call day (PCD) off as described by ACGME. The most important factors were the attending and chief resident feedback regarding PCDs.
Jabbour S, Fouhey D, Shepard S, et al. JAMA. 2023;330:2275.
Artificial intelligence (AI) is increasingly used in healthcare to support the diagnostic process, but concerns remain about the potential for error and bias. In this study, clinicians working at hospitals across 13 states were randomized to view a series of six AI diagnostic predictions with or without explanations and asked to determine the likelihood of whether the patient’s acute respiratory failure was attributable to pneumonia, heart failure, or chronic obstructive pulmonary disease (COPD). Each series of clinical vignettes also included three systematically biased vignettes. Clinicians’ baseline diagnostic accuracy for the three diagnoses was 73%; AI models with and without explanations improved diagnostic accuracy, but systematically biased models had a larger, adverse impact on diagnostic accuracy.
Carter D, Rosen A, Applebaum JR, et al. Jt Comm J Qual Patient Saf. 2023;Epub Oct 27.
The COVID-19 pandemic forced major changes to usual hospital care. This study of hospital medicine clinicians sought to understand individual and organizational responses to error reporting and communication, staffing, equipment, PPE and isolation practices, and infrastructure. More than half of respondents reported caring for more and/or sicker patients than usual, and a shortage of staff, equipment, and personal protective equipment (PPE). Qualitative responses suggest these factors had a negative impact on COVID patients, non-COVID patients, and staff.
Moore A, Knutsen Glette M. BMJ Open. 2023;13:e076136.
Clinicians are often influenced by cultural or system factors to continue working despite illness or fatigue, known as presenteeism. This qualitative study including nurses at three out-of-hours primary care facilities in Norway found that work-related stress is a significant contributor to presenteeism. Although participants felt that presenteeism did not adversely impact patient safety, the authors note the need for more research using non-subjective reporting systems to better understand patient safety implications.
Dukhanin V, McDonald KM, Gonzalez N, et al. Med Decis Making. 2024;44:102-111.
Patient engagement and shared decision-making are important components of diagnostic excellence. This study sought to understand if patients with emergency department visits in the previous 30 days agreed or disagreed with their diagnosis and their reasoning process. Understanding patients' reasoning regarding the accuracy of their diagnosis can inform clinical practice and research.
Havranek MM, Rüter F, Bilger S, et al. Int J Qual Health Care. 2023;35.
The AHRQ Patient Safety Indicators (PSIs) are used to identify patient safety events in acute care settings using administrative data. This retrospective study examined the performance of 16 PSIs across nine hospitals in Switzerland (where the indicators had not been previously applied). The authors attributed low positive predictive value (PPV) in three of the PSIs (pressure injury, falls, and perioperative embolism/thrombosis) to lack of present-on-admission (POA) information, whereas performance of several other indicators were not influenced by missing POA flags.
Giuffrida P, Davila S. Nursing. 2024;54:35-40.
Nurse burnout and overwork are recognized motivators for nurse turnover. This article describes how applying Maslow's hierarchy of needs to healthcare can increase nurse retention and reduce burnout. Interventions include ensuring staff receive competitive compensation, work to the top of their license, and have opportunities for continuing professional development.

Gilk T. Appl Radiol. 2023;52(6):24-26.

Magnetic resonance imaging (MRI) services carry with them unique safety considerations in both hospital and ambulatory scanning environments. This article discusses an existing guidance update that more completely covers a wide range of concerns to be addressed through tactics such as training, risk management, and checklists to improve the safe use of MRIs for both staff and patients.
Allen J, Sikora N. Clin Interv Aging. 2023;18:2093-2116.
Aging stigma and ageism can negatively impact a person's decision to seek care and the quality of care they receive. This review highlights the ways aging stigma is associated with health outcomes, including hospitalizations, cognition, psychological well-being, and physical health. The authors suggest future research includes sub-analysis with narrower age ranges (e.g., 10-year spans) instead of the typical range of 65 and older.
Degerman H, Wallo A. Appl Ergon. 2024;115:104165.
A cornerstone of resilience engineering is organizational learning. This scoping review summarizes how learning is discussed in current research. Descriptions include knowing what has happened; learning from the factual; learning from experience; knowing how to learn the right lessons from the right experience; learn from successes as well as failures; and adjusting the system.
Guerra-Paiva S, Lobão MJ, Simões DG, et al. BMJ Open. 2023;13:e078118.
Many clinicians experience emotional and/or psychological distress after involvement in an adverse event. This scoping review of 29 articles identified several factors supporting successful implementation of programs to support healthcare workers involved in patient safety incidents, including a non-punitive organizational culture and strong leadership engagement. The review also highlights the importance of peer support training and resource allocation (e.g., funding, protected time) to ensure program sustainability.
Pereira N, Duff JP, Hayward T, et al. J Am Med Inform Assoc. 2024;31:499-508.
Implementation of electronic health record (EHR) systems can present both improvements and threats in safety. This scoping review including 27 articles found wide variation in how medication safety is evaluated following EHR implementation. The authors propose a sociotechnical-based conceptual model to evaluate medication safety in future studies, including focusing on identifying technical and sociotechnical dependencies, developing EHR-specific definitions, and using multiple data sources to capture a comprehensive picture of safety.
Medeiros PB, Bailey C, Pollock D, et al. BMC Pediatr. 2023;23:573.
Near-miss events are often underreported, despite presenting opportunities for organizational learning and system changes. This systematic review identified no studies evaluating the effectiveness of neonatal near-miss audits for reducing perinatal morbidity and mortality, underscoring the need for well-designed, ethical studies examining this research question.
Meeting/Conference Proceedings

Agency for Healthcare Research and Quality. January 24, 2024.

Patient safety culture survey projects can yield important learnings if done correctly. The webinar detailed best practices for using the Surveys on Patient Safety Culture® (SOPS®). Speakers discussed the SOPS Surveys and Databases, getting started on administering the surveys, and increasing response rates.
Multi-use Website

American Hospital Association.

Leadership at the organization and system level is crucial to gaining improvement traction and sustainability. This initiative centers on safety culture, care inequities, and workforce issues to generate commitment toward the reduction of conditions that contribute to patient harm, and enhancement of public trust through strategic engagement from the executive team.

Littmann L. J Electrocardiol. 2023;81:32-35; 277-284. 2023. Epub Aug 15.

Overreliance on technology can open the door to a myriad of errors. This three-part illustrated article series provides insights for practitioners to recognize when computerized readings of electrocardiograms (ECGs) are wrong, to reduce misdiagnosis. Part 1 focuses on common interpretation software errors and false reporting of myocardial infarction, Part 2 looks at software errors that ironically helped to identify a correct diagnosis, and Part 3 highlights software errors that are crucial to catch in order to protect patients from serious harm.

Society to Improve Diagnosis in Medicine.

Rapid dissemination and review of new improvements actively being used can aid in the spread of innovations that improve care. This searchable database of professional-submitted diagnostic process improvements aims to collect information on tools and tactics organized around problems, contributing factors, organization type, and intervention characteristics.

Cantor AG, Jungbauer RM, Skelly AC, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2024. AHRQ Publication No. 24-EHC009.

Definitions of non-clinical aspects of care are important for developing effective measurement approaches that yield insights into success and failure. The evidence report highlights the importance of respectful maternity care (RMC) as a contributor to high-quality, safe care in general, and also for marginalized patient populations. The report reviews existing tools to measure RMC and found gaps in the evidence base on developing and activating strategies that support safe obstetric care and therefore, how they might affect patient outcomes.

This Month’s WebM&Ms

WebM&M Cases
Zachary Chaffin, MD |
A 9-year-old girl with cerebral palsy and epilepsy presented to the emergency department (ED) for increasing frequency of seizures lasting about 5 minutes, and developed hypoxic respiratory failure requiring endotracheal intubation, sedation, and mechanical ventilation. The pediatric neurology team ordered further testing, most of which had to be sent to an external laboratory and the results returned intermittently over several weeks. Several days into the hospital stay, acetylcholine receptor antibody test results returned markedly elevated at 302 nmol/L (normal is <0.5 nmol/L), which is concerning for myasthenia gravis. The laboratory finding that established this diagnosis was available in the electronic health record (EHR), but it was invisible to multiple teams of providers across multiple phases of care due to issues related to the EHR itself, challenges in clinical reasoning, and the workflow around transitions of care. The commentary highlights strategies to improve EHR systems to prevent diagnostic delays and care coordination for children with complex, chronic medical conditions
WebM&M Cases
Jihey Yuk, MD and Julia Magana, MD |
A 2-month-old boy was brought to the pediatric emergency department (PED) with a non-specific clinical picture of decreased responsiveness in the setting of a viral upper respiratory illness (URI) and appeared somnolent on initial evaluation. His pulmonary, cardiac, and abdominal examinations were unremarkable. He had normal muscle tone and movement of extremities and no bruising or abrasions were noted. Due to his persistently altered mental status, ultrafast magnetic resonance imaging (MRI) of the brain was obtained. Given limited overnight staffing, the MRI images were preliminarily read by a radiology resident. The patient was discharged with a parent after an “unremarkable” preliminary interpretation of the MRI. However, the next morning, the final reading of the MRI by the attending physician noted a small (5mm) subdural hemorrhage. The family was called back to the PED for further evaluation and a parent disclosed that the child had fallen off a bouncy seat placed on the bed, onto the floor, 3 days prior to presentation. The commentary discusses the pitfalls that clinicians encounter when they consider child abuse in the differential diagnosis and approaches to identifying non-accidental trauma (NAT) in pediatric patients.
WebM&M Cases
Spotlight Case
Jazmin A. Wander, MD and David K. Barnes, MD, FACEP. |
A woman presented to the emergency department (ED) for evaluation of a laceration to the palmer aspect of her left thumb. The treating clinician documented a superficial 3cm laceration and that the patient was unable to flex her thumb due to pain. The clinician closed the laceration with sutures. Neither a sensory examination nor wound exploration was documented. No fracture or foreign body was identified on x-ray but the procedure note did not mention whether the tendon was visualized. Several weeks after discharge from the ED, the patient was still unable to flex her thumb and was referred to an orthopedic surgeon and a hand specialist who surgically repaired a laceration to the flexor tendon. The commentary discusses the importance of including neurovascular and functional testing when evaluating hand injuries and the role of diagnostic imaging as well as strategies to improve diagnosis and mitigate human error when treating hand injuries.

This Month’s Perspectives

Richard Ricciardi
Interview
Richard Ricciardi, Ph.D., CRNP, FAANP, FAAN |
Richard Ricciardi is the associate dean for clinical practice and community engagement and the executive director of the Center for Health Policy and Media Engagement at the George Washington University. He has served as the director of the Division of Practice Improvement and senior advisor for nursing at AHRQ, and he maintains a part-time clinical practice at Mercy Health Clinic. We spoke to him on patient safety in office-based settings.
Jodi Sherman headshot
Interview
Jodi Sherman, MD |
Jodi Sherman is an associate professor of anesthesiology at Yale School of Medicine and is the director of the Yale Program on Healthcare Environmental Sustainability. She also serves as the medical director for the Yale New Haven Health System Center for Sustainable Healthcare. We spoke to her on patient safety and sustainable healthcare.
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