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February 21, 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

Iancu A, Leb I, Prokosch H-U, et al. Int J Med Inform. 2023;180:105241.
Pediatric medication management, in particular, requires precise dosing based on a wide range of variables including age, weight, and metabolism. This review sought to evaluate existing machine learning algorithms for medication dosing to determine which algorithms may perform best for children. Algorithms based on regression methods or decision trees performed best, but, because only 1 of the 36 studies were pediatric, significant further research is required.
Bernstein SL, Picciolo M, Grills E, et al. Jt Comm J Qual Patient Saf. 2023;Epub Dec 13.
Severe maternal morbidity continues to be a patient safety challenge. In this study, obstetric nurses and physicians describe unique system factors that affect obstetric nurses when their patients experience clinical deterioration in rural hospitals. Lack of resources included physical necessities such as a blood bank as well as human resources in the form of staff practicing "at the top of their game". The researchers describe a need for context specific policies and procedures for rural hospitals.
Rossi S, Hayter M, Zuco A, et al. Nurs Open. 2023;11:e2043.
Nurses play a significant role during transitions of care, such as discharge from inpatient care to the home. Findings from this systematic review of 15 studies confirm the role of nurses in ensuring high-quality care and patient safety in pediatric inpatient care. The review identified five essential elements that could be used in a checklist to ensure safe discharge to home – emergency management, physiological needs, medical device and medications management, and short-term and long-term management.
Bernstein SL, Picciolo M, Grills E, et al. Jt Comm J Qual Patient Saf. 2023;Epub Dec 13.
Severe maternal morbidity continues to be a patient safety challenge. In this study, obstetric nurses and physicians describe unique system factors that affect obstetric nurses when their patients experience clinical deterioration in rural hospitals. Lack of resources included physical necessities such as a blood bank as well as human resources in the form of staff practicing "at the top of their game". The researchers describe a need for context specific policies and procedures for rural hospitals.
Giese A, Khanam R, Nghiem S, et al. PLoS ONE. 2024;19:e0285285.
The Patient Safety Indicators (PSI) developed by the Agency for Healthcare Research and Quality aid healthcare organizations to identify potentially harmful events that compromise patient safety. This study from Switzerland shows the financial implications of PSI at a national level. The most common PSI was postoperative hemorrhage/hematoma (27.6%) and the highest cost by case was postoperative acute kidney injury (335% excess cost compared to matched control).
Pera V, van Vaerenbergh F, Kors JA, et al. Pharmacoepidemiol Drug Saf. 2023;33:e5743.
Medication errors and adverse drug events are an ongoing threat to patient safety. Using data from the Netherlands’ Food and Drug Administration’s Adverse Event Reporting System (FAERS) between 2004 and 2020, researchers found that 59% of reports were submitted by consumers and events most commonly involved chemotherapy and immunomodulating agents.
Michelson KA, Bachur RG, Rangel SJ, et al. JAMA Netw Open. 2024;7:e2353667.
Racial and ethnicity disparities can contribute to biases which can negatively impact health outcomes and patient safety. This retrospective cohort study including 93,136 children across nearly 1,000 EDs in the US between 2014 and 2019 found that Asian and Pacific Islander, Black, and Hispanic patients were more likely to experience delayed diagnosis of appendicitis and complications of appendicitis compared to White patients.
Konwinski L, Steenland C, Miller K, et al. J Patient Saf. 2024;20:209-215.
Independent double checking (IDC) has long been recommended to increase medication administration safety, but research on its effectiveness has been mixed. In this study, mandatory IDC were discontinued in a pediatric intensive care unit (except for total parental nutrition and chemotherapy which followed a different administration process). Administration error rates and patient harm were not different in the double checking and single checking periods, and nurse attitudes towards single checking improved during the single checking period.
Wickramasekera N, Hole AR, Rowen D, et al. Patient. 2024;Epub Feb 1.
Clinicians often cite fear of malpractice lawsuits as a reason to avoid apologizing after a patient safety incident or error. This study found that individuals are less likely to file a malpractice claims after a patient safety incident if they were satisfied with hospital’s investigation and if they received an apology.
Jones MD, Liu S, Powell F, et al. Drug Saf. 2024;47:389-400.
Guidelines support clinicians in safe decision making for a range of complex tasks but guidelines may also lead to patient harm. This study used medication errors reported to the National Reporting and Learning System for England and Wales to identify errors related to guideline use. Errors included inability to locate guidelines (e.g., website was down), not finding the relevant information within the guidelines (e.g., dosing for pregnant patients), and incorrect use of the information (e.g., disagreement between staff around meaning of information). Local, as opposed to national or organizational, guidelines were implicated in most errors and thus require further research.
Dalal AK, Schnipper JL, Raffel K, et al. J Hosp Med. 2023;19:140-145.
Diagnostic errors (DE) in the acute care setting can lead to longer lengths of stay, transfer to higher levels of care, and patient death. This article describes how the Utility of Predictive Systems in Diagnostic Errors (UPSIDE) Study identified and classified DE that resulted in transfer to ICU or potentially preventable death. Lessons from this DE review process can be implemented in other hospitals.
Miller MJ, Johansen ML, de Cordova PB, et al. Nurs Manage. 2024;55:32-42.
Previous research has found that nursing work environment can directly and indirectly affect patient safety. This analysis of Army Nurse Corps survey data identified favorable perceptions of nursing practice environment in US Army primary care practices. Survey respondents underscored the importance of supportive nursing leadership on nurse intent to leave and the role of career and professional development opportunities on job satisfaction.
Iancu A, Leb I, Prokosch H-U, et al. Int J Med Inform. 2023;180:105241.
Pediatric medication management, in particular, requires precise dosing based on a wide range of variables including age, weight, and metabolism. This review sought to evaluate existing machine learning algorithms for medication dosing to determine which algorithms may perform best for children. Algorithms based on regression methods or decision trees performed best, but, because only 1 of the 36 studies were pediatric, significant further research is required.
Finney RE, Jacob AK. Adv Anesth. 2023;41:39-52.
Staff who experience negative emotions or feelings after being involved in an adverse event are considered "second victims" and require organizational support. This article describes the creation and success of the second victim peer support program Healing Emotional Lives of Peers (HELP). Leadership support, dedicated personnel, and continuous engagement of trained peer supporters has led to HELP's implementation in additional departments and rapid expansion during COVID-19.
Murrar S, Baqai B, Padela AI. J Racial Ethn Health Disparities. 2024;11:150-156.
Disrespectful behavior in healthcare impedes the delivery of high quality, safe, and equitable care. This survey of Muslim American women in Chicago found that 25-30% of respondents reported not being listened to by their health care provider or treated with disrespect
Cevallos J, Lee C, Bongiovanni T. JAMA Netw Open. 2024;7:e2355014.
Despite evidence showing use of professional interpreters reduces disparities in care, they are not always utilized. This study investigated use of professional interpreters on patients with limited English proficiency (LEP) undergoing surgical procedures in one hospital. While 88% of patients utilized a professional interpreter at least once during their stay, only 3% used a professional interpreter at discharge. Given the complexity of post-surgical instructions, the researchers emphasize hospital discharge is an important area to improve rates of interpreter usage.
Sujan M, Lounsbury O, Pickup L, et al. Safety Sci. 2024;173:106450.
The Safety I and Safety II frameworks can be complementary, allowing organizations to focus both on eliminating errors (Safety I) and fostering resilience to understand how things usually go right (Safety II). This article provides an overview of the Systematic Human Error Reduction and Prediction (SHERPA) and Functional Resonance Analysis Method (FRAM) and examines their application in managing post-surgical deterioration from the Safety I and Safety II perspectives. 
Rossi S, Hayter M, Zuco A, et al. Nurs Open. 2023;11:e2043.
Nurses play a significant role during transitions of care, such as discharge from inpatient care to the home. Findings from this systematic review of 15 studies confirm the role of nurses in ensuring high-quality care and patient safety in pediatric inpatient care. The review identified five essential elements that could be used in a checklist to ensure safe discharge to home – emergency management, physiological needs, medical device and medications management, and short-term and long-term management.
No results.

Miliard M. Healthcare IT News. February 1, 2024.

Technologies provide improvements and introduce unique problems to care delivery. This article highlights a set of concerns regarding the use of health care technologies and their potential to undermine care safety. At-home medical devices, ransomware and artificial intelligence are among the technologies included in this annual compilation of technology threats in health care.
Alpharetta, GA: Society to Improve Diagnosis in Medicine; February 2024.
Patient and Family Advisory Councils (PFACs) can help to operationalize patient engagement in healthcare safety improvement work. This toolkit targets diagnostic excellence and educating PFAC members on the diagnostic process to enable their rich involvement in improvement work. The kit features videos, sections on the role of PFACs in diagnostic improvement, selected readings, letter templates and a glossary.

Healthcare Safety Investigation Branch (HSIB), Dorset, UK:  Health Services Safety Investigations Body; February 2024.

Patient misidentification can result in medication administration errors, missed test results and care delays that impact care safety. This National Learning Report examines circumstances that contribute to poor identification practices and shares recommendations targeting the organizational and policy actions to improve patient identification practice.

Oakbrook Terrace, IL: Joint Commission and National Quality Forum; February 13, 2024.

The annual Eisenberg Award recognizes leaders and organizations who have made significant national and local contributions toward patient safety and quality improvement. The 2023 honorees are Eduardo Salas, PhD, Veterans Health Administration, and BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium).

Tscholl DW, Hunn CA, Gasciauskaite G. APSF Newsletter. 2024;39:29–30.

Situation awareness is a crisis management concept drawn from aviation safety to be used in examination of complex care situations to understand failures and design improvement strategies. This article introduces situation awareness and how lack thereof can jeopardize patient safety.

Willyard C. MIT Technology Review. February 9, 2024.

Engineers play an important role in the development and manufacturing of medical devices with an eye toward human factors to enable their safe use. This article discusses efforts to address structural flaws in pulse oximeter design to improve their accuracy on patients of color.

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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