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February 7, 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

Ali KJ, Goeschel CA, Eckroade MM, et al. Jt Comm J Qual Patient Saf. 2024;50:95-103.
All team members have a role in ensuring diagnostic excellence. This study describes the development and psychometric evaluation of the TeamSTEPPS for Improving Diagnosis Team Assessment Tool (TAT). Team members from nine healthcare organizations representing inpatient, surgery, and ambulatory care completed the TAT. Analysis supported the TAT as a viable tool for assessing teamwork and communication across the diagnostic team.
Dmowska A, Fielding‐Singh P, Halpern J, et al. Birth. 2024;51:209-217.
Women of color frequently report that their race has impacted the quality of care they receive. In this study, women of color who experienced a traumatic birth described the racist and gendered stereotypes ascribed to them (uneducated, negligent, (in)tolerant to pain, and dramatic) and how those stereotypes impacted the obstetrical care they received. Ultimately these experiences caused long-term harm to their mental health, decreased trust in healthcare, and reduced the desire to have children in the future.
Lamé G, Liberati EG, Canham A, et al. BMJ Qual Saf. 2024;33:246-256.
Electronic fetal monitoring is widely used but can lead to preventable patient harm. Using a human factors and ergonomics approach based on the SEIPS model, this study explored the work processes and system factors influencing the use of electronic fetal monitoring. The authors discuss the role of staffing and workload, equipment/space design and function, escalation processes, and clinical competence to detect and address fetal deterioration.
Yerstein MC, Sundararaj D, McClean M, et al. J Psychiatr Pract. 2024;30:68-72.
Incident reporting systems can provide insights into the factors contributing to patient harm and offer opportunities for shared learning. In this retrospective study, researchers evaluated safety incidents reported using the Psychiatry Morbidity and Mortality Incident Reporting Tool (PMMIRT) and proposed a revised categorization to better understand the types of safety incidents encountered in psychiatric care.
Alterio RE, Abreu AA, Meier J, et al. Curr Probl Surg. 2024;61:101426.
Healthcare is costly for patients and payors, yet higher prices may not correlate with better care. This study evaluated the incidence of Patient Safety Indicators (PSI) after pancreatectomies in hospitals with higher and lower markup ratios (proportion between charges and costs billed by a hospital for a determined service). Hospitals with a higher markup ratio had a higher incidence of PSI, and a higher markup ratio was not associated with higher quality.
Roosan D, Padua P, Khan R, et al. J Am Pharm Assoc (2003). 2024;64:422-428.e8.
There is increasing interest in the use of artificial intelligence, such as ChatGPT, to support clinical decision making. This study evaluated the ability of ChatGPT to resolve simple and complex medication therapy management cases. The researchers found that ChatGPT was able to solve 100% of the patient cases, identifying drug interactions and providing therapy recommendations and general management plans, suggesting that AI has the potential to support pharmacists and other healthcare providers in safe medication management.
Fonseca Â, Ferreira A, Ribeiro L, et al. Eur J Neurol. 2024;31:e16195.
Large language models (LLM) such as ChatGPT are potentially useful tools to improve healthcare, particularly in diagnosis. In this study, researchers submitted 188 scenarios from the American Academy of Neurology's Question of the Day app to ChatGPT-3.5, and compared mean success rates between the app's users and ChatGPT. There were no statistically significant differences between app users’ and ChatGPT’s success rate. Nevertheless, substantial research is still required before LLM and other artificial intelligence applications can be used safely in clinical practice.
Järvisalo P, Haatainen K, Von Bonsdorff M, et al. J Adv Nurs. 2023;Epub Dec 10.
Clinicians require support (often referred to as the second victim phenomenon) after involvement in patient safety incidents. In this study, nurse managers outline effective interventions and suggest that standardized support, such as full team debriefing after all patient safety incidents, can minimize the negative impact on nurses' well-being as well as reduce burden and attrition risks and positively impact patient safety.
Kaplan HC, Goldstein SL, Rubinson C, et al. Am J Med Qual. 2024;39:21-32.
Organizational context can serve as a driver or barrier to the implementation of patient safety interventions. This qualitative study identified several contextual factors impacting the implementation of the pharmacist-driven Nephrotoxic Injury Negated by Just-In-Time Action (NINJA) intervention. Hospitals succeeding in reducing medication-related acute kidney injury were more likely to have additional pharmacy support and/or a nephrologist team member with organizational support.
Dmowska A, Fielding‐Singh P, Halpern J, et al. Birth. 2024;51:209-217.
Women of color frequently report that their race has impacted the quality of care they receive. In this study, women of color who experienced a traumatic birth described the racist and gendered stereotypes ascribed to them (uneducated, negligent, (in)tolerant to pain, and dramatic) and how those stereotypes impacted the obstetrical care they received. Ultimately these experiences caused long-term harm to their mental health, decreased trust in healthcare, and reduced the desire to have children in the future.
Ali KJ, Goeschel CA, Eckroade MM, et al. Jt Comm J Qual Patient Saf. 2024;50:95-103.
All team members have a role in ensuring diagnostic excellence. This study describes the development and psychometric evaluation of the TeamSTEPPS for Improving Diagnosis Team Assessment Tool (TAT). Team members from nine healthcare organizations representing inpatient, surgery, and ambulatory care completed the TAT. Analysis supported the TAT as a viable tool for assessing teamwork and communication across the diagnostic team.
Ong N, Lucien A, Long JC, et al. Health Expect. 2024;27:e13925.
Children with intellectual disability are known to be at increased risk of poor quality of care and patient safety events. This qualitative study, which included parents of children with intellectual disability, explored patient safety issues encountered during their child’s care. Parents highlighted the importance of parental roles as safety advocates, the harm of dismissive attitudes from care providers, the role of communication and coordination to foster trust, and care environments and providers with the resources and training to promote disability-specific patient safety.
Lamé G, Liberati EG, Canham A, et al. BMJ Qual Saf. 2024;33:246-256.
Electronic fetal monitoring is widely used but can lead to preventable patient harm. Using a human factors and ergonomics approach based on the SEIPS model, this study explored the work processes and system factors influencing the use of electronic fetal monitoring. The authors discuss the role of staffing and workload, equipment/space design and function, escalation processes, and clinical competence to detect and address fetal deterioration.
Kerr E, Kant V. Theor Issues Ergon Sci. 2024;25:1-20.
Understanding why patient safety incidents take place is important for preventing recurrence. This article describes two types of failure in the relationships between people and technology: ambiguity-based failure (lack of clarity of user roles) and expectation-based failure (discrepancy between anticipated and actual system performance).

Jalali M, Dehghan H, Habibi E, et al. Int J Prev Med. 2023;14:127.

Human Factor Analysis and Classification System (HFACS) in healthcare is used to identify human factors that may contribute to adverse events. This review found 12 studies that used HFACS for coding, cause analysis, and categorization of adverse events. Preconditions for unsafe acts (e.g., equipment design, communication) were identified as a major cause of errors and adverse events.
Wang Y, Ram SS, Scahill S. Int J Qual Health Care. 2024;36:mzad114.
Patient complaints can provide important opportunities for learning and inform safety improvement efforts. This scoping review examined risk factors and predictors of complaints and misconduct against health care providers. Based on 81 included studies, the authors identified practitioner characteristics (e.g., education, medical specialty, workload) and system or environmental characteristics (e.g., practice size, geographic location) that can predict complaints and misconduct.
Honarmand K, Wax RS, Penoyer D, et al. Crit Care Med. 2024;52:314-330.
Rapid recognition and response to patient deterioration is a crucial element of safe inpatient care. This guideline is comprised of 10 statements focusing on identification of deterioration in patients outside of the intensive care unit (ICU). Recommendations include organization-wide rapid response team activation criteria, patient deterioration training, and accurate vital sign monitoring.
No results.

Khan S, Cholankeril R, Sloane J, et al. Rockville, MD: Agency for Healthcare Research and Quality; January 2024. Publication no. 24-0010-1-EF.

Diagnostic errors have emerged as a primary patient safety concern. This issue brief presents the results of a rapid narrative review and expert interviews to determine the current state of diagnostic safety and highlights key gaps in knowledge. The brief covers the past decade of progress in the field and identifies the current state of science and gaps in diagnostic safety work within 10 domains. This issue brief is part of a series of AHRQ-supported publications on diagnostic excellence.

Sanchez JA, Higgins RSD, Kent PS, eds. St Louis, MO: Elsevier; 2024.  ISBN: 9780323661799.

Surgical care is recognized as a complex activity. This book discusses a range of topics that affect the safety of surgery. The overall scope looks at surgery through the prism of safety science. Chapters cover topics such as teamwork, human factors, and safety culture.
Special or Theme Issue

Nutr Clin Pract. 2023;38(6):1181-1415.

Effective nutrition provision in the hospital environment can be complicated and prone to error. This special issue offers insights and evidence on various aspects of safe enteral and parenteral nutrition provision such as compounding, tube placement, and line entanglement.

This Month’s WebM&Ms

WebM&M Cases
Christian Bohringer, MBBS and Linda Vo, MD |
A 47-year-old obese man with hypertension fell and suffered a cervical spine (C5/C6) fracture. He was scheduled for urgent anterior cervical decompression and fusion and was transferred to the operating room (OR) where general anesthesia was induced. During the procedure, his expired tidal volume decreased from 560 ml to about 330 ml. He was manually ventilated through the endotracheal tube, which proved very difficult. An urgent chest X-ray did not reveal any pneumothorax. The Black Belt cervical retractor was released by the surgeon resulting in complete resolution of the airway obstruction. The commentary highlights the importance of vigilant monitoring and good communication to identify and respond to life-threatening events and describes approaches to improve crisis management during anesthesia events.
WebM&M Cases
Timothy Do, BS and Fiona J Scott, MD, MPH, MS, MHI |
A 32-year-old woman was admitted to the hospital for endoscopic retrograde cholangiopancreatography (ERCP) under monitored anesthesia care (MAC). As the endoscope was advanced into the stomach, the patient vomited. She was immediately turned supine but copious vomitus obstructed the suction catheter. The patient started to decompensate with decreasing oxygen saturation. The anesthesia team attempted to secure the airway by endotracheal intubation but was unable to place a tube due to poor view and vomitus. The patient went into cardiac arrest and ultimately passed away. The commentary discusses safety considerations for ERCP under MAC, weighing the risks and benefits of MAC versus general anesthesia, and airway management during emergencies.
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

This Month’s Perspectives

Stephen Hines headshot
Interview
Monika Haugstetter, MHA, MSN, RN, CPHQ; Stephen Hines, PhD |
Monika Haugstetter, MHA, MSN, RN, CPHQ, is a Health Science Administrator with AHRQ, leading AHRQ’s TeamSTEPPS® initiative. Stephen Hines, PhD, is a Senior Research Scientist at the Arbor Research Collaborative for Health. While at Abt Associates, he co-led the TeamSTEPPS 3.0 revisions in collaboration with AHRQ. We spoke with Monika and Stephen about the newly released TeamSTEPPS 3.0 curriculum.
Perspective
Monika Haugstetter, MHA, MSN, RN, CPHQ; Stephen Hines, PhD; Zoe Sousane, BS; Sarah Mossburg, RN, PhD |
This piece discusses the impact of AHRQ’s TeamSTEPPS training curriculum on patient safety and highlights updates made to the curriculum in 2023 with the launch of TeamSTEPPS 3.0.
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