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January 31, 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

Eriksson CO, Bahr N, Meckler G, et al. JAMA Netw Open. 2024;7:e2351535.
Adverse safety events (ASE) are common in pediatric out-of-hospital cardiac arrests (OHCA). This retrospective chart review study sought to estimate the prevalence of adverse safety events in children under age 18 experiencing OHCA. The researchers found that 60% of those children experienced at least one severe ASE, with the highest odds of ASE occurring when the OHCA was birth-related.
Gallagher TH, Kachalia A. New Engl J Med. 2024;390:193-197.
Communication and resolution programs (CRP) detail effective ways that healthcare organizations and professionals should respond to and disclose medical errors and adverse events. This commentary advocates for implementation of CRPs in all healthcare systems while acknowledging several challenges: leadership and organizational commitment; fear of liability; balance between transparency and legal confidentiality privileges; and maintaining patient trust during the disclosure process.
Haylor H, Sparkes T, Armitage G, et al. BJPsych Bull. 2024;Epub Jan 4.
Root cause analysis is frequently used to investigate serious adverse events, but it may not be appropriate for organizational learning from suicide investigations. This review identified alternative investigative methods such as Safety II and inclusion of the patient in investigations. The authors also note that an upstream focus on regulatory bodies and healthcare organizations is needed.
Mastalerz KA, Jordan SR, Townsley N. J Hosp Med. 2024;19:92-100.
Research shows that bedside interdisciplinary rounds (IDR) improve communication and foster collaboration between interprofessional members of the care team. In this study, resident and attending physicians shared their perspectives on IDR in an academic hospital. Both residents and attendings felt that IDR improved patient-centered care. Residents reported IDR felt like just an additional task they had to perform despite also recognizing the benefits.
Zhang HL, Crane L, Cromer AL, et al. Infect Control Hosp Epidemiol. 2024;45:103-105.
Healthcare-associated infections (HAIs) remain a significant cause of preventable morbidity and mortality in hospitalized patients and a source of financial burden to the healthcare system. Researchers in this study estimated the attributable costs of central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), hospital-onset Clostridioides difficile infection (CDI-HO), and surgical site infections (SSI) across 45 hospitals between January 2016 and December 2022. Event rates ranged from 0.34 events per 1,000 patient days (CDI-HO) to 0.87 events per 1,000 procedures (SSI), with events costing nearly $1 million per hospital on an annual basis.
Eriksson CO, Bahr N, Meckler G, et al. JAMA Netw Open. 2024;7:e2351535.
Adverse safety events (ASE) are common in pediatric out-of-hospital cardiac arrests (OHCA). This retrospective chart review study sought to estimate the prevalence of adverse safety events in children under age 18 experiencing OHCA. The researchers found that 60% of those children experienced at least one severe ASE, with the highest odds of ASE occurring when the OHCA was birth-related.
Carroll AR, Johnson JA, Stassun JC, et al. JAMA Netw Open. 2024;7:e2350969.
Parents administering liquid medication to children can experience difficulties in administering correct doses. This prospective, randomized trial provided either standard discharge medication instructions or an intervention which included teach-back and pictograms. Parents in the intervention arm were less likely to have dosing errors and demonstrated greater recall of medication dose and duration.
Urwin R, Pavithra A, Mcmullan RD, et al. BMJ Open Qual. 2023;12:e002413.
Unprofessional behaviors among health care workers can impede safety culture and harm patients and colleagues. In this study, researchers examined 2,504 reports of positive and unprofessional coworker behavior over a three-year period at one Australian hospital. The most commonly reported positive behaviors included non-technical skills, values-driven behavior, and actions that enhanced patient care delivery. Frequently reported unprofessional behaviors included being rude, humiliating or ridiculing others, and ignoring others’ opinions.
Amat MJ, Anderson TS, Shafiq U, et al. Jt Comm J Qual Patient Saf. 2024;50:177-184.
Primary care residents' clinic rotations and their ultimate graduation may result in failure to follow up on pending diagnostic referrals, or "failure to close the diagnostic loop." This study aimed to determine rates of diagnostic test referral completion between patients of resident and attending physicians. Patients with resident referrals were less likely to close the diagnostic loop than patients of attending physicians. Referral completion rates were lower than recommended for both groups and the authors propose solutions to increase rates.
Beran T, Altabbaa G, Oddone Paolucci E. Adv Med Educ Pract. 2023;14:1445-1452.
Simulations provide a safe way to observe interpersonal interactions and communication. In this simulation study, a researcher posing as a preceptor offered an incorrect diagnosis to a medical student and resident to understand if the learners would conform to the preceptor. 38% of student/resident dyads conformed to the preceptor's incorrect diagnosis. Moreover, all the students conformed to the resident but not to the preceptor, suggesting learners may be more likely to conform to a person with the next higher status in the hierarchy.
McElroy C, Skegg E, Mudgway M, et al. J Surg Res. 2023;295:567-573.
Debriefing is an important tool to improve individual and team performance as well as to identify opportunities for improvement. In this qualitative study involving operating room staff and clinicians, participants cited teamwork and commitment to learning, psychological safety, and effective leadership as key factors necessary for effective debriefing.
Rivera-Chiauzzi EY, Huang L, Osborne AK, et al. J Patient Saf. 2024;20:28-37.
Peer support programs are increasingly used to support providers experiencing emotional or psychological distress after involvement in an adverse event. This article describes the Healing Emotional Lives of Peers (HELP) peer support program, which includes psychological first aid, one-on-one peer support, and supportive resources. The article also describes its implementation at one academic medical center. Qualitative feedback from participants who completed a self-assessment indicate that the program promotes a culture of safety and supports judgement-free support.
Kuehn BM. JAMA. 2024;Epub Jan 17.
Medical history has been tainted with a range of biases over a long period of time that are currently being addressed via training, decision making support and patient engagement. This essay introduces several efforts underway to address biased algorithms and how they can distort decision making tools to cause harm.
Booth JP, Hartman AD. Hosp Pharm. 2024;59:47-55.
Intensive strategies are required to prevent high-risk medication errors from reaching the patient. This article describes the development of a framework to identify common causes of medication errors and human factors-related strategies to prevent harm such as manufacturer or organizational premixed/prefilled products and separate storage.
Verma AA, Trbovich PL, Mamdani MM, et al. BMJ Qual Saf. 2024;33:121-131.
Artificial intelligence and machine learning present both opportunities and threats to patient safety. This article highlights machine learning applications in quality improvement and patient safety (e.g., decision support) and practice considerations before deploying machine learning applications (e.g., presence of underlying biases). The authors provide several recommendations for optimizing implementation of machine learning applications in healthcare settings.
Marshall SE. Nurs Manage. 2023;54:30-35.
Medication reconciliation is a valuable step towards avoiding drug treatment inconsistencies across transitions in care. This article shares implementation insights gleaned from a brown-bag initiative that anchored a multidisciplinary approach to medication verification and reconciliation in the community setting.
Gallagher TH, Kachalia A. New Engl J Med. 2024;390:193-197.
Communication and resolution programs (CRP) detail effective ways that healthcare organizations and professionals should respond to and disclose medical errors and adverse events. This commentary advocates for implementation of CRPs in all healthcare systems while acknowledging several challenges: leadership and organizational commitment; fear of liability; balance between transparency and legal confidentiality privileges; and maintaining patient trust during the disclosure process.
Mello MM, Guha N. N Engl J Med. 2024;390:271-278.
Artificial intelligence (AI) has the potential to enhance health care, but there are still concerns regarding its use. This article discusses the challenges in applying existing liability law principles to the increasing use of AI in healthcare. The authors discuss risk management approaches that clinicians and organizations can use to manage AI-related liability risk.
Pereira SC de A, Ribeiro OMPL, Fassarella CS, et al. BJGP Open. 2024;Epub Jan 9.
Characteristics of the nursing work environment, such as nurse staffing and safety culture, can affect patient safety. This scoping review explored the role of the nursing work environment on safety culture in primary care settings. The researchers identified several characteristics of nursing work environments that can impact safety (e.g., leadership, communication, organizational culture) but note that additional research is needed to identify effective strategies to improve nursing work environments and promote safe primary care.
Haylor H, Sparkes T, Armitage G, et al. BJPsych Bull. 2024;Epub Jan 4.
Root cause analysis is frequently used to investigate serious adverse events, but it may not be appropriate for organizational learning from suicide investigations. This review identified alternative investigative methods such as Safety II and inclusion of the patient in investigations. The authors also note that an upstream focus on regulatory bodies and healthcare organizations is needed.
No results.

Washington, DC: The Veterans Affairs Inspector General; January 10, 2024. Report No. 23-00777-52.

Communication delays are a common contributor to serious patient harm. This analysis examines a case of communication failure during cardiac telemetry processes that resulted in patient death. Communication gaps at the time of clinical deterioration affected nurse assignments and delays in care, and the subsequent review of the patient's care failed to identify systemic and causal factors.
Special or Theme Issue

Jt Comm J Qual Patient Saf. 2024;50(1);1-92.

Health care inequities are the result of both clinical and community system failures. This special issue highlights activities in the field that examine investigative methods to better understand the systemic nature of health equity challenges and how to address them to improve patient safety.

Rascoe A, Gorenstein D. National Public Radio. January 21, 2024.

Openness about making mistakes is a challenge in health care due to fear of litigation, fear, and career damage. This companion podcast presents insights from individuals affected by medical error on the importance of organizational support using strategies such as communication and resolution programs to encourage apologies and transparency when errors occur.

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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