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January 24, 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

Kappy B, Berkowitz D, Isbey S, et al. Am J Emerg Med. 2023;77:139-146.
Patient boarding (i.e., time from admission order to transfer to inpatient unit) in adult emergency departments (ED) has been associated with poorer patient outcomes. This study assessed the impact of boarding times in one pediatric emergency department (PED) from 2018 to 2022. Increased boarding time was associated with increased length of overall hospital stay for patients admitted to hospital wards, but not for patients admitted to the intensive care unit.
Mccullough K, Baker M, Bloxsome D, et al. J Clin Nurs. 2023;Epub Nov 12.
Clearly defined and tracked outcome measures are necessary for evaluation of health services. In the hospital setting, clinical deterioration as a nurse-sensitive outcome (NSO) measure is widely recognized and clearly defined, yet there is a lack of clarity around NSO in out-of-hospital settings. This review identified 34 studies and reviews of clinical deterioration in community settings, such as ambulatory or home care. Contributing factors were similar to those identified in hospitals, including workload, staff mix, and education.
Webster CS, Coomber T, Liu S, et al. J Patient Saf. 2024;20:57-65.
Interprofessional learning (IPL) is a common strategy to improve patient safety. This systematic review of quantitative evidence found that healthcare provider participation in interventions including IPL led to significant reductions in adverse events and mortality compared to conventional patient care.
Samuels-Kalow ME, Tassone R, Manning W, et al. JAMA Netw Open. 2024;7:e2351629.
Children are vulnerable to medication administration errors at home. This study describes the implementation and sustainment of the Medication Education for Dosing Safety (MEDS) intervention, a program to educate parents and caregivers about safe medication administration at discharge from the emergency department. The risk of administration error was reduced after the intervention and, while the risk increased slightly during the sustainment phase, it remained lower than at baseline.
Wat SK (S), Wesolowski B, Cierniak K, et al. J Oncol Pharm Pract. 2023;Epub Dec 27.
Medication errors involving chemotherapy can lead to serious patient harm. This retrospective study examined medication errors involving chemotherapies reported at one hospital oncology infusion center before and after implementation of an electronic chemotherapy order verification (ECOV) checklist. After ECOV implementation, reported medication errors increased, indicating that the checklist provided an additional opportunity for pharmacists to identify errors, including near misses.
Kappy B, Berkowitz D, Isbey S, et al. Am J Emerg Med. 2023;77:139-146.
Patient boarding (i.e., time from admission order to transfer to inpatient unit) in adult emergency departments (ED) has been associated with poorer patient outcomes. This study assessed the impact of boarding times in one pediatric emergency department (PED) from 2018 to 2022. Increased boarding time was associated with increased length of overall hospital stay for patients admitted to hospital wards, but not for patients admitted to the intensive care unit.
Bergl PA, Shukla N, Shah J, et al. Diagnosis (Berl). 2023;Epub Nov 30.
Misdiagnosis is a major contributor to morbidity and mortality in the intensive care unit (ICU). This study sought to understand the diagnostic accuracy of ICU attendings, fellows, advanced practice providers, and nurses. Contextual factors of self-reported confidence in the diagnosis, stress levels, and perception of patient's prognosis were analyzed as potential influencers on accuracy.
Alspaugh A, Swan LET, Auerbach SL, et al. Cult Health Sex. 2023;25:1690-1706.
Healthcare-associated stigma can inhibit patients from seeking care. This study explored women’s negative experiences with healthcare providers in Appalachia. When seeking general health care, two-thirds of women reported mistreatment that made them not want to seek care in the future. When seeking care for contraception, one in six reported a negative, stigmatizing experience. Dehumanizing treatment, low-quality care, and healthcare misogyny were all identified as factors contributing to stigma.
Webber C, Milani C, Bjerre LM, et al. J Am Med Dir Assoc. 2024;25:130-137.e4.
Potentially inappropriate prescribing (PIP) is common and can contribute to patient harm, including adverse drug events, functional decline, and death. This population-based study including over 171,000 long-term care residents in Ontario, Canada, examined the relationship between PIP and probable delirium. Researchers found that residents with three or more instances of PIP (measured by STOPP/START and Beers criteria) were significantly more likely to have probable delirium compared to residents with no instances of PIP.
Wachter RM. JAMA Intern Med. 2024;184:127-128.
System failures affecting individuals or populations provide lessons for learning and improvement. This discussion of commonalities between medical error and COVID-19 shares how data and stories, appropriate mental models, risk assessment and communication, and consistent, focused effort by the front line and leaders should be harnessed to address unexpected yet likely challenges to both patient safety and public health.
Stucky CH, Michael Hartmann J, Yauger YJ, et al. J Perianesth Nurs. 2024;39:10-15.
Near misses (or close calls) are often underreported but can offer unique opportunities for organizational learning. In this article, the authors present 15 perioperative near-miss events (e.g., medication administration errors, wrong-site surgery, allergies), describe the contributing factors, and discuss approaches to improve incident reporting among perioperative care team members.
Mccullough K, Baker M, Bloxsome D, et al. J Clin Nurs. 2023;Epub Nov 12.
Clearly defined and tracked outcome measures are necessary for evaluation of health services. In the hospital setting, clinical deterioration as a nurse-sensitive outcome (NSO) measure is widely recognized and clearly defined, yet there is a lack of clarity around NSO in out-of-hospital settings. This review identified 34 studies and reviews of clinical deterioration in community settings, such as ambulatory or home care. Contributing factors were similar to those identified in hospitals, including workload, staff mix, and education.
Cassidy CE, Boulos L, McConnell E, et al. Explor Res Clin Soc Pharm. 2023;12:100365.
E-prescribing is common and has improved many patient outcomes, but is not without risks. In this review, 35 studies on the safety of e-prescribing in community settings were identified. Most studies reported on error rates and were descriptive in nature; only five reported patient health outcomes. The authors recommend additional research on interventions to improve e-prescribing safety.
Webster CS, Coomber T, Liu S, et al. J Patient Saf. 2024;20:57-65.
Interprofessional learning (IPL) is a common strategy to improve patient safety. This systematic review of quantitative evidence found that healthcare provider participation in interventions including IPL led to significant reductions in adverse events and mortality compared to conventional patient care.
Tekletsion BF, Gomes JFDS, Tefera B. J Contingencies Crisis Manage. 2024;32:e12495.
Resilience is a characteristic enabling individuals or organizations to adapt to disturbances or uncertain conditions without compromising safety. This systematic review examined the interrelated demands and tensions arising as organizations pursue resilience before, during, and after crises.
Uchmanowicz I, Lisiak M, Wleklik M, et al. Med Sci Monit. 2024;30:e942031.
Incomplete nursing care can decrease patient satisfaction and threaten patient safety. This systematic review including 15 studies found that rationing of nursing care (i.e., intentional withholding or delay in essential nursing care) adversely impacts patient safety, contributing to higher incidence of falls, medication errors, pressure injuries, and healthcare-associated infections. The authors of the review discuss several hospital characteristics (i.e., workload, staffing levels, experience) that contribute to rationing of nursing care.
Paxino J, Szabo RA, Marshall SD, et al. BMJ Qual Saf. 2023;Epub Dec 30.
Clinical debriefing is important to learn from significant clinical events and it is implemented in many clinical settings. This review characterizes the clinical contexts, timing, and intentions of debriefing. Creating and using a consistent terminology for debriefing will enhance implementation and research into this practice.
No results.

Washington DC: VA Office of the Inspector General; January 4, 2024; Report no. 22-02294-42.

System fragmentation is known to enable clinicians with performance issues to remain in practice and risk patient safety. This report examines credentialing practices at a community care network weakened by interorganizational communication gaps, data inconsistencies, and information failures. The investigators also noted patient safety reporting problems that could be addressed through enhanced communication and staff training.

Goldstein J. New York Times. January 14, 2024.

Maternal safety is challenged in the Unites States and particularly for minorities. This news article discusses care problems during a cesarean birth for a black mother who died. Factors contributing to her death include delayed recognition of deterioration, and communication failures.

Szabo L. NBC News. January 15, 2024.

Diagnostic errors undermine patient safety at a substantial rate, but more so for women, and people of color. This article discusses reasons for this disparity including implicit bias and clinician workload.

Freyer FJ. Boston Globe. January 13, 2024.

The surgical black box uses cameras and microphones to record procedures in real time for analysis. This article discusses the marriage of black box technology with artificial intelligence as a tool to examine minute activities in the operating room to enable learning from both success and failure, and generate improvement.

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; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD |
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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