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March 13, 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

Hooven K, Altmiller G. AORN J. 2024;119:152-160.
Fear of retaliation by leaders or colleagues can prevent staff from reporting adverse events, unsafe conditions, or near misses. This article presents strategies to improve just culture in the perioperative environment, which is prone to hierarchical structure. Strategies include creating an accessible reporting system, implementation of a "good catch" program, and leadership support for staff who submit reports.
Holmes L, Enwere M, Mason R, et al. Healthcare (Basel). 2024;12:477.
Structural racism in the healthcare system and beyond contributes to disproportionally high mortality for Black children. In this study, researchers compared mortality rates of Black and white infants using the International Classification of Diseases (ICD) subclass Misadventures to Patients During Surgical and Medical Care, where the authors defined misadventures as "the fatal medical errors that occur among healthcare providers, such as the slipping of a scalpel or administration of an incorrect dosage or drug." During the study period of 1968 - 2015, results show Black infants were at significantly higher risk of dying from medical misadventure than were white infants.
Marcin JP, Lieng MK, Mouzoon J, et al. JAMA Netw Open. 2024;7:e240275.
Medication errors among children remain a patient safety challenge. This cluster randomized trial evaluated medication errors among critically ill children presenting to the Emergency Department (ED) and randomized to receive either video telemedicine or telephone consultations with pediatric critical care physicians. A physician-related medication error occurred in 12.5% of participants overall, with no statistically significant differences between the video telemedicine or telephone consultation groups.
Hassan B, Tawfik M-M, Schiff E, et al. Jt Comm J Qual Patient Saf. 2024;50:279-284.
In situ simulation can identify latent safety threats before they reach a patient. In this study, 20 multidisciplinary teams participated in in situ simulations of a tracheostomy emergency in an adult patient. Only ten of the teams were able to reestablish the airway within the allotted five minutes, and 12 types of human errors and 15 types of latent safety threats were identified.
DeGennaro AP, Gonzalez N, Peterson SM, et al. Diagnosis (Berl). 2024;11:97-101.
Diagnostic uncertainty is common, particularly in the emergency department (ED) or urgent care where patients are typically unknown to the provider, and the goal of care is to provide a patient with a plan, such as follow-up with primary care provider. In this study, patients and care partners describe their experiences with diagnostic uncertainty in the ED or urgent care. 73% reported poor communication with the most common subtheme being poor explanation.
Kendal S, Louch G, Walker L, et al. J Psychiatr Ment Health Nurs. 2024;Epub Jan 27.
Patient safety issues in mental health care settings are understudied. This qualitative study evaluated the implementation of ‘WardSonar,’ a tool designed to digitally monitor and communicate safety perceptions from adult acute mental health patients to staff. Feedback from patients and staff was generally positive, although some staff reported that they did not need the tool to understand patients’ safety concerns.
Ojute F, Gonzales PA, Berler M, et al. J Surg Educ. 2024;81:514-524.
Psychological safety among care providers, including residents, can foster patient safety and promote clinician wellbeing. This mixed-methods study explored general surgery residents’ perceptions of psychological safety support in the workplace and the relationship between psychological safety and resident wellbeing. Findings underscore the importance of supportive mentorship as well as a culture that embraces and destigmatizes asking for help.
Holmes L, Enwere M, Mason R, et al. Healthcare (Basel). 2024;12:477.
Structural racism in the healthcare system and beyond contributes to disproportionally high mortality for Black children. In this study, researchers compared mortality rates of Black and white infants using the International Classification of Diseases (ICD) subclass Misadventures to Patients During Surgical and Medical Care, where the authors defined misadventures as "the fatal medical errors that occur among healthcare providers, such as the slipping of a scalpel or administration of an incorrect dosage or drug." During the study period of 1968 - 2015, results show Black infants were at significantly higher risk of dying from medical misadventure than were white infants.
Woodier N, Burnett C, Sampson P, et al. J Patient Saf Risk Manag. 2023;29:47-53.
Near-miss patient safety events offer unique learning opportunities. This qualitative study explored patient safety learning from near-miss events in the National Health Service. Participants noted the limited processes available for reporting near-miss events and insufficient support for reporting near-miss events, which can hinder opportunities for learning.
Obadan-Udoh E, Howard R, Valmadrid LC, et al. J Patient Saf. 2024;20:177-185.
Patient safety issues in dentistry are receiving increasing attention. Based on 67 individual patient interviews, researchers in this study explored patient perspectives about the impact of dental diagnostic errors. Participants identified several categories of contributing factors, including clinician issues (e.g., poor communication), patient issues (e.g., lack of self-advocacy), and system factors (e.g., insurance challenges, workload).
Westbrook JI, Li L, Woods AL, et al. Stud Health Technol Inform. 2024;310:329-333.
Medication administration errors remain a common cause of preventable harm. This randomized trial investigated the impact of an electronic medication system on medication administration errors among pediatric patients at one referral hospital in Sydney, Australia. After implementation, researchers found no significant impact on medication errors with potential for serious harm or errors involving high-risk drugs.
Marcin JP, Lieng MK, Mouzoon J, et al. JAMA Netw Open. 2024;7:e240275.
Medication errors among children remain a patient safety challenge. This cluster randomized trial evaluated medication errors among critically ill children presenting to the Emergency Department (ED) and randomized to receive either video telemedicine or telephone consultations with pediatric critical care physicians. A physician-related medication error occurred in 12.5% of participants overall, with no statistically significant differences between the video telemedicine or telephone consultation groups.
Facey M, Baxter NN, Hammond Mobilio M, et al. Sociol Health Illn. 2024;Epub Feb 1.
Surgical safety checklists (SSC) have been shown to improve patient safety, but several studies have exposed they are not always completed as intended. This ethnographic study concludes, thorough interviews, surveys, and observations, that the SCC tends to be completed as a perfunctory task, not to improve patient safety.
Hooven K, Altmiller G. AORN J. 2024;119:152-160.
Fear of retaliation by leaders or colleagues can prevent staff from reporting adverse events, unsafe conditions, or near misses. This article presents strategies to improve just culture in the perioperative environment, which is prone to hierarchical structure. Strategies include creating an accessible reporting system, implementation of a "good catch" program, and leadership support for staff who submit reports.
Hunt DF. BMJ Lead. 2024;Epub Jan 17.
Psychological safety is critical for all staff in health systems, including leadership. This article encourages leaders to acknowledge their limitations, as this creates a culture of trust and enables innovation by including a wide range of stakeholders. The authors also acknowledge challenges associated with displaying vulnerability and strategies to overcome them.
Whitaker DK, Lomas JP. Anaesthesia. 2024;79:119-122.
Simplifying complex processes is a strategy to engineer safety into health care. This article discusses the use of prefilled syringes as a tactic to reduce the potential for error in intravenous medication administration. The author argues for broader acceptance of this strategy across the practice of anesthesiology.
Goldberg CB, Adams L, Blumenthal D, et al. NEJM AI. 2024;1.
Artificial intelligence (AI) is increasingly being used and studied in healthcare. This perspective shares insights from the RAISE (Responsible AI for Social and Ethical Healthcare) conference, highlighting that AI in healthcare needs to enhance patient care, support healthcare professionals, and be accessible and safe for all.
Um IS, Clough A, Tan ECK. Res Social Adm Pharm. 2024;20:1-9.
Pharmacy dispensing errors continue to be a source of preventable harm. Based on a systematic review of 62 studies, these authors report a global pooled prevalence of medication dispensing errors of 1.6% (range, 0-33%) across community, hospital, and other pharmacy settings.
Im DS, Tamarelli CM, Shen MR. J Gen Intern Med. 2024;39:283-300.
When a physician's unprofessional behavior is reported by patients, families, or staff, an appropriate investigation must be conducted. While the investigations are critical for ensuring patient safety, physicians experience negative emotional and mental impacts, as well as changes to their clinical practice (e.g., defensive medicine). This review summarizes studies on physicians' experiences during and after investigations and mitigation strategies.

Healthcare Quality Institute. March 28, 2024, 2:00 -3:00 PM (eastern).

Central line associated bloodstream infections (CLABSIs) are a long-standing, preventable threat to patient safety. This webinar will highlight one health system’s successful multidimensional approach to eliminating CLABSIs in their organization for three years.

Agency for Healthcare Research and Quality. Fed Register. Mar 6, 2024;89(45);15992.

A standard system for voluntary reporting to patient safety organizations improves measurement of errors in the hospital environment. This announcement calls for the review of Common Formats for Surveillance – Hospital Version 1.0, and supplies links to the draft formats for public comment. The process for submitting comments is open until April 5, 2024.

Booth G, ed.  Anamnesis. MedPage Today. March 1, 2024.

The dismissal of patient health concerns by providers degrades diagnosis, treatment, and trust. This collection of three podcasts illustrates gaslighting as experienced by clinicians in the diagnosis of brain tumors, individual denial of illness, and delayed recognition of long Covid due to weight bias.

This Month’s WebM&Ms

WebM&M Cases
Caitlin Loseth, MD |
A 60-year-old woman with a history of cirrhosis arrived at the emergency department (ED) with an open right ankle injury and moderate blood loss after falling at home. A tourniquet was placed and her initial point-of-care hemoglobin was 7 mg/dl, so a “massive transfusion protocol” was initiated. The patient progressed to cardiac arrest and chest tubes were placed on both sides of the chest. After return of spontaneous circulation, fluid was identified in the abdomen, so the patient was immediately transferred to the operating room (OR) for exploratory laparotomy. Bleeding was noted to be coming from lacerations in the lateral chest wall and in the right lateral aspect of the liver, which was enlarged and visibly cirrhotic with splenomegaly. Multiple packing maneuvers were attempted but definitive hemorrhage control could not be obtained. This commentary highlights the challenges in managing blunt trauma in actively bleeding patients with a history of cirrhosis and the importance of frameworks and protocols (e.g., Advanced Trauma Life Support [ATLS], Massive Transfusion Protocol [MTP]) to protect against misadventures in the trauma bay.
WebM&M Cases
Spotlight Case
Claudia López, MD and Véronique Taché, MD |
A patient who was 39-weeks pregnant presented to the hospital in active labor, admitted to the Labor and Delivery unit and confirmed to have a full-term singleton fetus in vertex presentation. After several hours on oxytocin, the fetal head was still relatively high and the fetal heart rhythm suggested hypoxemia. The physician attempted delivery using a vacuum, but ultimately performed an emergency cesarean delivery of a healthy newborn. The procedure was complicated by the need to extend the lower uterine segment incision bilaterally for safe extraction of the fetus. The operator’s note described post-delivery repair of the right uterine incision but did not comment on the left side. Following the delivery, the patient was noted to be hypotensive and tachycardic and went into cardiac arrest. Another physician opened the patient’s incision and found nearly three liters of blood had collected in her abdomen, apparently due to complete transection of the left uterine artery. The commentary highlights the risk factors for obstetric hemorrhage, summarizes standardized risk assessments used to alert for potential obstetric hemorrhage and use of obstetric simulation training to improve team communication and performance.
WebM&M Cases
Spotlight Case
James A. Bourgeois, OD, MD and Glen Xiong, MD |
An 18-year-old woman with no significant past medical history was admitted to a community hospital for evaluation and treatment of acute psychosis with paranoid delusions and started on an antipsychotic medication. On hospital day 7, the nurse practitioner learned from the patient’s father that there was a family history of systemic lupus erythematosus (SLE) and suggested that the patient be evaluated for lupus. Laboratory tests indicated borderline pancytopenia, an elevated antinuclear antibody (ANA), and abnormally elevated anti-double-stranded DNA, but these laboratory tests were not evaluated until 2-3 days after discharge and the patient was never referred for further evaluation. The commentary discusses the clinical manifestations of a primarily psychiatric presentation of SLE, the importance of family history when evaluating patients with psychotic presentations, and the need for clear communication between medical specialists to ensure safe, high-quality care.

This Month’s Perspectives

Barbara Pelletreau photograph
Interview
Barbara Pelletreau, RN; John Riggi |
John Riggi is the national advisor for cybersecurity and risk at the American Hospital Association. Barbara Pelletreau is a former senior vice president of patient safety for a large healthcare organization. We spoke to them about the risks of cybersecurity to patient safety and how organizations can prepare and respond to cyberattacks.
Patrick Tighe photograph
Interview
Patrick Tighe, MD, MS |
Patrick Tighe, MD, MS, is a practicing anesthesiologist at University of Florida Health (UF Health) and the executive director of UF Health’s Quality and Patient Safety Initiative. We spoke to him about the current and potential impacts of artificial intelligence (AI) on patient safety as well as challenges to successful implementation.
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