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January 17, 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

Auerbach AD, Lee TM, Hubbard CC, et al for the UPSIDE Research Group. JAMA Intern Med. 2024:184(2):164-173.

Diagnostic errors can result in significant morbidity and mortality. This large cohort study reviewed the health records of 2,428 adult inpatients who were transferred to the intensive care unit (ICU) and/or died in the hospital to estimate frequency, cause, and harms of diagnostic errors. Nearly a quarter (23.0%) of patients in the cohort experienced a diagnostic error, and 6.6% of patients who died had a diagnostic error. Delays in ordering and interpreting tests and problems with clinical assessment were the most common contributing factors resulting in transfer to ICU and/or death.
Bansal N, Campbell SM, Lin C-Y, et al. BMC Med. 2024;22:5.
Regulatory bodies, health systems, and researchers are continuously investigating methods to ensure safe opioid prescribing for patients with chronic pain. This study engaged clinicians, pharmacists, and independent prescribers to evaluate opioid prescribing scenarios and rate them as inappropriate, uncertain, or appropriate. Fifteen out of the 21 scenarios were rated as inappropriate (i.e., could result in harm to patients) and can be used to support decision making for appropriate prescribing and deprescribing for patients with chronic pain in primary care.
Henry Basil J, Premakumar CM, Mhd Ali A, et al. Int J Qual Health Care. 2023;35:mzad101.
Medication administration errors (MAE) in the neonatal intensive care unit (NICU) are prevalent. This study of NICU nurses sought to ascertain reasons for MAE and reasons for not reporting MAE. The most common reasons for MAE were inadequate staffing followed by look-alike drugs. The most common reason for not reporting MAE was leadership placing blame on the individual instead of on system-level factors.
Weaver BW, Murphy DJ. Jt Comm J Qual Patient Saf. 2023;Epub Oct 30.
Effective teamwork and communication are cornerstone to the delivery of safe patient care. This article describes the development of a mixed methods toolkit (including a behavior observation tool, semi-structured interview guide, and surveys) to assess and improve teamwork and communication issues. Researchers applied the toolkit in 14 units across three hospitals with positive feedback from unit leadership.
Weaver BW, Murphy DJ. Jt Comm J Qual Patient Saf. 2023;Epub Oct 30.
Effective teamwork and communication are cornerstone to the delivery of safe patient care. This article describes the development of a mixed methods toolkit (including a behavior observation tool, semi-structured interview guide, and surveys) to assess and improve teamwork and communication issues. Researchers applied the toolkit in 14 units across three hospitals with positive feedback from unit leadership.
Bansal N, Campbell SM, Lin C-Y, et al. BMC Med. 2024;22:5.
Regulatory bodies, health systems, and researchers are continuously investigating methods to ensure safe opioid prescribing for patients with chronic pain. This study engaged clinicians, pharmacists, and independent prescribers to evaluate opioid prescribing scenarios and rate them as inappropriate, uncertain, or appropriate. Fifteen out of the 21 scenarios were rated as inappropriate (i.e., could result in harm to patients) and can be used to support decision making for appropriate prescribing and deprescribing for patients with chronic pain in primary care.
Barile J, Margolis A, Cason G, et al. JAMA Pediatr. 2024;Epub Jan 2.
Clinicians and the public are increasingly interested in using chatbots like ChatGPT to learn more about their care, particularly for diagnoses. This study asked ChatGPT to provide a differential diagnosis list and final diagnosis for 100 pediatric case studies. ChatGPT had an overall error rate of 83%. Among incorrect diagnoses, many were clinically related to the final diagnosis, but too broad to be classified as correct, and just over half were of the same organ system. Despite the error rate, authors still thought that large language models (LLMs) could be helpful to clinicians as a tool, and recommend that teaching chatbots may improve diagnostic accuracy.

Auerbach AD, Lee TM, Hubbard CC, et al for the UPSIDE Research Group. JAMA Intern Med. 2024:184(2):164-173.

Diagnostic errors can result in significant morbidity and mortality. This large cohort study reviewed the health records of 2,428 adult inpatients who were transferred to the intensive care unit (ICU) and/or died in the hospital to estimate frequency, cause, and harms of diagnostic errors. Nearly a quarter (23.0%) of patients in the cohort experienced a diagnostic error, and 6.6% of patients who died had a diagnostic error. Delays in ordering and interpreting tests and problems with clinical assessment were the most common contributing factors resulting in transfer to ICU and/or death.
Bell SK, Amat MJ, Anderson TS, et al. J Am Med Inform Assoc. 2024;Epub Jan 2.
Prompt completion of diagnostic tests or referrals is paramount to receiving a timely diagnosis and treatment. In this study, completion rates for three common diagnostic tests or referrals (i.e., colonoscopy, concerning skin lesions, cardiac stress test) were compared between patients who do not access a patient portal; patients who do have access but do not read visit notes; and patients who have access and who do read visit notes. Completion rates were highest for patients who read visit notes (62%) compared with those who do not read notes (57%) and those with no portal use (54%). The authors state timely completion rates for all groups remain below recommend thresholds and increased patient engagement is required.
Rivera-Chiauzzi EY, Riggan KA, Huang L, et al. J Patient Saf Risk Manag. 2023;28:253-259.
Individuals working in obstetrics and gynecology (OBGYN) settings commonly report second victim experiences. This qualitative study with OBGYN and pediatric staff at one large academic medical center identified a need for both an immediate support program (e.g., peer support programs) as well as long-term support for lingering psychological symptoms.
Co Z, Classen DC, Cole JM, et al. Appl Clin Inform. 2023;14:981-991.
Computerized provider order entry (CPOE) alert prescribers to potentially unsafe medication orders, such as drug-drug interactions or dosing errors. In this study, ten outpatient clinics used the Ambulatory Electronic Health Record (EHR) Evaluation Tool to evaluate the ability of their CPOE to detect medication safety errors. Scores varied widely between clinics and between order entry categories (e.g., a low of 3% for drug monitoring and high of 100% for drug-allergy).
Henry Basil J, Premakumar CM, Mhd Ali A, et al. Int J Qual Health Care. 2023;35:mzad101.
Medication administration errors (MAE) in the neonatal intensive care unit (NICU) are prevalent. This study of NICU nurses sought to ascertain reasons for MAE and reasons for not reporting MAE. The most common reasons for MAE were inadequate staffing followed by look-alike drugs. The most common reason for not reporting MAE was leadership placing blame on the individual instead of on system-level factors.
Kneifati-Hayek JZ, Geist E, Applebaum JR, et al. BMJ Qual Saf. 2024;33:132-135.
Near misses (also referred to as close calls) represent important opportunities for safety improvement. Using retrospective data from January 1 to December 31, 2019, this study calculated the proportion of wrong-patient imaging orders involving radiation that are intercepted, and those that reached the patient. The researchers estimated an overall rate of 51.5 per 100,000 imaging orders involving wrong-patient orders, with 50 near-miss events for every 1 error that reached the patient.
Mileder LP, Schwaberger B, Baik-Schneditz N, et al. BMJ Open Qual. 2023;12:e002567.
In situ simulation training can identify latent safety threats (LSTs) before they cause patient harm. Researchers in this study conducted 13 one-day in situ simulation trainings of neonatal emergencies at one Austrian hospital over an eight-year period and identified 67 LSTs. The most common categories of LSTs involved equipment (63%), resources (21%), and medications (16%).
Djärv T. Resusc Plus. 2023;17:100525.
Reporting patient safety events allows incidents to be tracked over time and identifies significant changes. This study reviewed and categorized incident reports regarding in-hospital cardiac arrest (IHCA) at two hospitals in Sweden to reduce IHCA and improve survival rates. The largest category included documentation and patient decision making errors, followed by pre-arrest care. Quarterly and annual tracking of reports allowed for prompt interventions such as implementation of a standardized form in the electronic health record instead of free text for documenting patient decisions.
Karanikas N, Zerguine H. Safety Sci. 2023;170:106367.
Key safety and risk management concepts from domains such as aviation (e.g., crew resource management) can be leveraged in healthcare settings to improve patient safety. This article discusses emerging safety and risk management concepts (referred to as new safety paradigms or NSPs) such as high reliability and resilience engineering, and their potential value to organizational safety when applied in healthcare settings.
Shoemaker MJ, Collins SM. Phys Ther. 2023;103:pzad125.
The aviation industry often provides inspiration and guidance to steer patient safety improvement work. This article summarizes key safety concepts from aviation – including crew resource management, situational awareness, and checklists – that can be applied to physical therapist education and practice.
Labrague LJ. West J Nurs Res. 2023;46:52-63.
Healthcare leadership displaying disruptive and unprofessional behavior can have detrimental effects on worker and patient safety. This systematic review explored the nurse-related and patient safety outcomes associated with abusive supervision. Among 21 included studies, common outcomes included turnover intention, job satisfaction, workplace violence, and psychological well-being/burnout. The authors also identified several mediators of abusive supervision.
Alhawajreh MJ, Paterson AS, Jackson WJ. PLoS ONE. 2023;18:e0294180.
Much research has been done into patient outcomes at accredited versus non-accredited hospitals, but less research has focused on accreditation as a quality improvement tool or on contextual factors influencing implementation. This systematic review summarizes findings from research into how accreditation impacts quality improvement in hospitals as well as barriers and facilitators of implementation. The findings are mapped to Normalization Process Theory concepts of coherence, cognitive participation, collective action, and reflexive monitoring.
Min D, Park S, Kim S, et al. J Patient Saf. 2024;20:77-84.
Older adults living in nursing homes are highly vulnerable to patient safety problems. Based on 47 articles, this integrated literature review identified three categories of systemic factors impacting the safety and health outcomes of older adults living in nursing homes. The categories include personal factors (e.g., medical needs, specialized care needs), institutional factors and characteristics (e.g., staffing and skill mix, safety culture, staff training and education), and policy/external support factors (e.g., finances, primary payor source).
No results.

Princeton, NJ: Robert Wood Johnson Foundation; January 2024.

The financial structure of healthcare can contribute to harm for both patients and communities, especially those experiencing marginalization. This grant announcement seeks proposals to explore policy and socioeconomic factors degrading care delivery due to systemic racism and the marketization of healthcare. The deadline to apply is February 12, 2024.

Tran Y, Ellis LA, Clay-Williams R, eds. Lausanne, Switzerland: Frontiers Media SA; 2023. ISBN 9782832540770.

Healthcare must address workforce issues to ensure patient safety and support staff wellbeing. This book is a compiled set of pre-published articles that examine issues of workforce safety and culture and how they intersect with care delivery success in a variety of countries. Topics covered include the importance of safety investigation and safety culture assessment.

Dorset, UK: Health Services Safety Investigations Body; December 2023.

Retained surgical items are never events that continue to occur despite efforts to reduce their occurrence. This interim report examines reasons for 31 incidents of retained surgical swabs reported in the United Kingdom’s National Health Service (NHS). Recommendations from the analysis focus on organizational work to limit the opportunities for swab retention that target system improvement rather those that lower impact changes directed toward staff behavior and training.

McGrory K, Bedi N. ProPublica, January 6, 2024.

Stories of mental health system failure provide important insights to raise awareness of ineffective care conditions that reduce patient safety. This news article shares the experiences of two veterans whose fragmented psychological care in a rural community culminated in criminal harm, incarceration, and delayed healing.

Hare R, Tyler ER, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2023. AHRQ Publication no. 23(24)-0095.

Ambulatory surgery centers harbor unique characteristics that affect safety culture. The latest publication in this analytical series from the Agency for Healthcare Research and Quality (AHRQ) shares results of 243 ambulatory surgery centers (ASCs) participating in the Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey. Most respondents (91%) rated their organization as committed to learning and continuous improvement, with only 72% noting that enough staff were on hand to manage the work.

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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