Sorry, you need to enable JavaScript to visit this website.
Skip to main content

February 28, 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

Kotwal S, Howell M, Zwaan L, et al. J Gen Intern Med. 2024;Epub Jan 26.
Achieving diagnostic excellence is a primary focus in health care. In this qualitative study, researchers interviewed hospitalists at five hospitals to examine clinical lessons learned from diagnostic errors and successes. Five themes were identified: excellence in clinical reasoning as a core skill; elucidating insights from patients and other care team members; reflecting on the diagnostic process; commitment to a growth mindset; and prioritizing self-care and well-being.
Michelson KA, Rees CA, Florin TA, et al. JAMA Pediatr. 2024;178:362-368.
Diagnostic delays in the emergency department (ED) are a serious patient safety concern. This retrospective cohort study included children treated at 954 EDs across 8 states, and examined the association between ED volume and delayed diagnosis of first-time diagnosis of an acute, serious conditions (e.g., bacterial meningitis, compartment syndrome, stroke). The researchers found that EDs with lower pediatric volume had higher rates of delayed diagnosis across 23 serious conditions. 
Parikh K, Hall M, Tieder JS, et al. Pediatrics. 2024;153:e2023063714.
Disparities in healthcare are emerging as a core patient safety issue. This population-based retrospective study examined disparities in the AHRQ pediatric safety indicators (PDIs). The findings indicate that Black and Hispanic pediatric patients have a higher risk of safety events (particularly sepsis and postoperative respiratory failure) compared to white patients. Findings were similar when comparing patients with Medicaid versus private insurance.
Hassinger AB, Velez C, Wang J, et al. J Clin Sleep Med. 2024;20:221-227.
The link between hours worked, hours slept, and medical errors has been the topic of much research, policy, and debate. This study captured sleep timing, regularity, efficiency, and duration via Fitbit in more than 3,500 interns (i.e., first year medical residents). There was no association between sleep duration and self-reported medical errors or burnout. Interns with the worst sleep health did have higher rates of burnout, compared to those with the best; however, as a group, interns had poor sleep health.
Parikh K, Hall M, Tieder JS, et al. Pediatrics. 2024;153:e2023063714.
Disparities in healthcare are emerging as a core patient safety issue. This population-based retrospective study examined disparities in the AHRQ pediatric safety indicators (PDIs). The findings indicate that Black and Hispanic pediatric patients have a higher risk of safety events (particularly sepsis and postoperative respiratory failure) compared to white patients. Findings were similar when comparing patients with Medicaid versus private insurance.
Michelson KA, Rees CA, Florin TA, et al. JAMA Pediatr. 2024;178:362-368.
Diagnostic delays in the emergency department (ED) are a serious patient safety concern. This retrospective cohort study included children treated at 954 EDs across 8 states, and examined the association between ED volume and delayed diagnosis of first-time diagnosis of an acute, serious conditions (e.g., bacterial meningitis, compartment syndrome, stroke). The researchers found that EDs with lower pediatric volume had higher rates of delayed diagnosis across 23 serious conditions. 
Kotwal S, Howell M, Zwaan L, et al. J Gen Intern Med. 2024;Epub Jan 26.
Achieving diagnostic excellence is a primary focus in health care. In this qualitative study, researchers interviewed hospitalists at five hospitals to examine clinical lessons learned from diagnostic errors and successes. Five themes were identified: excellence in clinical reasoning as a core skill; elucidating insights from patients and other care team members; reflecting on the diagnostic process; commitment to a growth mindset; and prioritizing self-care and well-being.
Magerøy MR, Macrae C, Braut GS, et al. Front Health Serv. 2024;4:1275743.
Effective nursing leadership can improve patient safety climate. This qualitative study explored how nursing home leadership in Norway balances environmental and patient safety objectives. Respondents discussed the importance of communication, effective leadership, and building systems that further a culture of safety.
King L, Minyaev S, Grantham H, et al. Jt Comm J Qual Patient Saf. 2024;50:269-278.
Patient- and visitor-activated rapid response systems (RRS) allow for earlier detection and prevention of clinical deterioration. This study sought perspectives of nurses and physicians on how patient and visitor involvement in RRS impacted care of other patients, their role in educating consumers on clinical deterioration, and the impact on the organization. The clinicians were generally positive about consumer involvement, but were also concerned that it could increase their workload, both by responding to more frequent activations, and by providing additional consumer education.

Aiken LH, Sermeus W, McKee M, et al. BMJ Open. 2024;14(2):e079931.

Physician and nurse burnout, job dissatisfaction, and intention to leave the job have increased in recent years, exacerbated by the pandemic. Results of this study of physicians and nurses in six European hospitals show poor work/life balance, high burnout, and high intention to leave. Among interventions to improve working conditions, nurses most frequently endorsed increased nurse staffing and physicians endorsed reducing bureaucracy and red tape. Individual mental health interventions received the lowest ratings.
Ayre MJ, Lewis PJ, Phipps DL, et al. Front Psychiatry. 2023;14:1241445.
Medication errors and adverse drug events (ADE) are common in community settings including primary care, general practice, mental health services, and community pharmacy. This study focused on factors contributing to ADE, specifically in patients with mental illness receiving care in the community. Several factors were similar to those in other patient populations (e.g., workforce shortages) but some were also unique to this patient group, including lack of knowledge of psychotropic medications, difficultly in contacting and following up with patients, and diffusion of provider responsibility.
Feliciano-Rivera YZ, Yepes MM, Sanchez P, et al. J Breast Imaging. 2024;Epub Jan 24.
Patients with limited English proficiency (LEP) are at higher risk of receiving suboptimal care, and they are less likely to receive preventative healthcare, including screening mammograms, than are native English speakers. This article lays out the benefits to patients of professional interpreters and best practices for engaging with the interpreter and patient in the breast radiology setting. Certified medical interpreters are recommended (and sometimes legally mandated) in place of ad hoc interpreters such as the patient's family members. While in-person professional interpreters are most effective, telephone and video are more accessible and less costly.
Januel J-M, Southern DA, Ghali WA. BMC Med Inform Decis Mak. 2023;21:385.
The International Classification of Diseases, 11th revision (ICD-11), introduces new features that enable a more detailed description of healthcare-related and patient safety events. This article provides examples of how ICD-11 allows coding for causal factors via "connecting terms." The authors state the new rich data provided by ICD-11 can improve adverse event reporting and research.
Gong Y, Chen Y. Stud Health Technol Inform. 2024;310:324-328.
Non-routine events (NRE), or deviations from optimal care, are latent safety threats, and their early identification and elimination can improve patient safety. This article uses an example of a medication error in the intensive care unit presented in a PSNet WebM&M case and commentary to describe NRE in the context of time-dependent tasks and teamwork, the use of real-world data to investigate them, and the challenges of identifying NRE.
Sarkar U, Bates DW. JAMA Intern Med. 2024;184:343-344.
Artificial intelligence (AI) has the potential to improve care delivery in a variety of healthcare settings. This article describes how AI tools can be leveraged in primary care and provides several examples, such as supporting clinician documentation, between-visit management and communication, and individualized decision support.  
Ciudad-Gutiérrez P, del Valle-Moreno P, Lora-Escobar SJ, et al. J Med Syst. 2023;48:2.
Medication reconciliation at transition of care ensures patients are correctly receiving medications prescribed to them. This review explored studies on electronic medication reconciliation tools available to healthcare providers. Twelve tools were identified, four of which showed a reduction in adverse drug events or medication discrepancies; however, none showed a decrease in emergency room visits or hospital readmissions. Clinicians requested that these tools be incorporated into the medication ordering software and that they be made more user-friendly.
New L, Lambeth T. Nurs Clin North Am. 2024;59:141-152.
The second victim phenomenon (SVP) refers to clinicians who experience continued psychological harm after involvement in a patient safety incident. This article outlines the physical, psychological, and professional manifestations of SVP, and how organizational programs can target the various stages of recovery to support healthcare workers after a patient safety incident.
Steel EJ, Janda M, Jamali S, et al. J Patient Saf. 2024;20:125-130.
Morbidity and mortality (M&M) conferences remain an important opportunity for patient safety education and feedback. This systematic review concluded that implementing standardized structures and processes within M&M meetings (e.g., standardized case selection), along with organizational support, is associated with learning and system improvement.

Centers for Medicare & Medicaid Services, March 6 and 21, 2024. 12:00 - 1:00 PM (eastern).

Quality measurement intersects with patient safety and care improvement efforts to track weaknesses in distinct areas of performance. This webinar will share the experiences of government entities working to proactively reduce conditions that contribute to preventable patient harm through innovative use of quality measures.

Fernandez H, Ayo-Vaughan M, Zephyrin LC, et al. New York, NY: The Commonwealth Fund; February 15, 2024.

Clinicians and health care workers that closely interface with patients are apt to perceive important relational characteristics affecting care. This report summarizes data examining discriminatory actions observed by health care workers within care exchanges and found that close to 50% of those surveyed had witnessed biased interactions associated with patient primary language, race, and ethnicity.

Hum Factors. 2024;66(3):633-769.

The ergonomics community has an established interest in medical error reduction. The 2021 International Ergonomics Association conference examined applications of human factors core concepts and methods to health care. Health care information technologies, workarounds, and nontechnical skills measurement are discussed through the lens of human factors.

Hare R, Tyler ER, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2024. AHRQ Publication No. 24-0028.

The Agency for Healthcare Research and Quality's (AHRQ) Medical Office Survey on Patient Safety Culture is designed to assess safety culture in the outpatient environment. This analysis shares survey results from 1,164 participating offices of various structures and patient care focuses. Patient care tracking/follow-up and teamwork were the areas of focus receiving the highest composite scores.

Seattle, WA: Collaborative for Accountability and Improvement; 2023.

There is a need for patients and families to understand effective routes for action should they experience harm. This FAQ shares steps for patients and families to take to help them get the communication and resolution they need from organizations and clinicians to effectively resolve concerns.

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.
Stay Updated!
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. Sign up today to get weekly and monthly updates via emails!