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March 27, 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

Chavez Ortiz JL, Griffin I, Kazakova SV, et al. Transfusion. 2024;Epub Mar 12.
Blood transfusion errors, while rare, can be severe and potentially fatal. This study used eight years of transfusion-related errors reported to the National Healthcare Safety Network (NHSN) Hemovigilance Module to quantify errors, adverse events, and blood wastage. Most reported errors were near misses and occurred during sample collection, sample handling, and product administration. Error reporting declined significantly during the study period; the researchers state efforts are underway to decrease reporting burden and increase participation in the NHSN Hemovigilance Module.
Crozier N, Robinson E, Murtagh NC, et al. Hosp Pharm. 2024;59:210-216.
The Institute for Safe Medication Practices (ISMP) hierarchy of effectiveness of risk-reduction strategies ranks interventions from the least to most effective. Using 665 pharmacy-related medication safety reports at one hospital, researchers evaluated the actionability of the reports on the ISMP hierarchy. Three-quarters of the reports were only actionable at the least effective levels (e.g., suggestions to "be more careful", educational programs). The researchers suggest events that lent themselves to more effective levels of intervention were acted upon and, therefore, recurred less frequently.
Dellve L, Skagert K. Safety Sci. 2024;174:106488.
Rates of transmission of COVID-19 were high in nursing homes for both residents and staff with wide variation in implementing infection control measures. This study describes the gaps between infection control work-as-imagined and work-as-done in nursing homes and home health before and during the pandemic. Gaps included instructions for personal protective equipment created for hospitals that were not practical for providing care inside a recipient's homecare or nursing home.
Crozier N, Robinson E, Murtagh NC, et al. Hosp Pharm. 2024;59:210-216.
The Institute for Safe Medication Practices (ISMP) hierarchy of effectiveness of risk-reduction strategies ranks interventions from the least to most effective. Using 665 pharmacy-related medication safety reports at one hospital, researchers evaluated the actionability of the reports on the ISMP hierarchy. Three-quarters of the reports were only actionable at the least effective levels (e.g., suggestions to "be more careful", educational programs). The researchers suggest events that lent themselves to more effective levels of intervention were acted upon and, therefore, recurred less frequently.
Parikh NR, Francisco LS, Balikai SC, et al. Jt Comm J Qual Patient Saf. 2024;Epub Jan 24.
The I-PASS tool is a commonly-used tool to improve handoff quality. This study evaluated the usability of the I-PASS-to-PICU (Pediatric Intensive Care Unit) tool, which is designed to support handoffs between referring clinicians and receiving PICU physicians. Testing with a small group of PICU physicians using simulated and actual handoff calls indicated good feasibility.
Dellve L, Skagert K. Safety Sci. 2024;174:106488.
Rates of transmission of COVID-19 were high in nursing homes for both residents and staff with wide variation in implementing infection control measures. This study describes the gaps between infection control work-as-imagined and work-as-done in nursing homes and home health before and during the pandemic. Gaps included instructions for personal protective equipment created for hospitals that were not practical for providing care inside a recipient's homecare or nursing home.
Batthish M, Kuper A, Fine C, et al. J Healthc Qual. 2024;46:100-108.
Morbidity and mortality (M&M) conferences have evolved from focusing on individual clinicians to system errors. In this study, researchers observed M&M conferences, interviewed leadership, and reviewed M&M policies at three Canadian hospitals to describe how organizational learning is enacted. Although the hospitals differed in policies and processes, all three acknowledged the importance of recognizing organizational trends and learning from errors at both the individual and system levels. PSNet offers an online version of M&M conferences with an emphasis on systems learning.
Rodriguez JA, Samal L, Ganesan S, et al. J Patient Saf. 2024;Epub Mar 13.
The COVID-19 pandemic led to dramatic changes in healthcare delivery and presented new challenges to safe patient care. Among patients ages 18 years and older admitted to the hospital between January 2019 and June 2020, this study found that the first surge of the COVID-19 pandemic was not associated with an increase in patient safety events (measured using the AHRQ patient safety indicators) among patients without COVID-19. Among the individual PSIs, only in-hospital falls with hip fractures were significantly higher during the first surge of the pandemic.
Forrest C, O'Sullivan MJ, Ryan M, et al. Breast. 2024;75:103699.
Patient safety issues impacting cancer care can have significant impacts on patients. This cross-sectional survey of physicians and patients at one cancer center in Ireland explored perspectives about patient safety and medical errors in breast cancer care. Patients and physicians reported deteriorations in patient safety and highlighted long-term implications of involvement in patient safety issues.
Chavez Ortiz JL, Griffin I, Kazakova SV, et al. Transfusion. 2024;Epub Mar 12.
Blood transfusion errors, while rare, can be severe and potentially fatal. This study used eight years of transfusion-related errors reported to the National Healthcare Safety Network (NHSN) Hemovigilance Module to quantify errors, adverse events, and blood wastage. Most reported errors were near misses and occurred during sample collection, sample handling, and product administration. Error reporting declined significantly during the study period; the researchers state efforts are underway to decrease reporting burden and increase participation in the NHSN Hemovigilance Module.
Adler-Milstein J, Redelmeier DA, Wachter RM. JAMA. 2024;Epub Mar 14.
Humans are apt to err, and a reliance on their overt watchfulness is unreliable. This commentary discusses the downsides of the overreliance of human oversight on artificial intelligence (AI) to ensure its safe use. The authors suggest design strategies to enhance the effectiveness of human vigilance on the safe use of AI in health care.
Cadet T, Cusimano J, McKearney S, et al. J Interprof Care. 2023;Epub Dec 20.
Interprofessional education (IPE) emphasizes collaborative care to improve health outcomes. In this scoping review, 94 articles that linked IPE to at least one of ten CMS quality measures (e.g., medication errors, readmission rates) were identified. The majority included learners from medicine and nursing, with much less representation from other professions, and fewer than one-third included students. Most clinical outcomes improved or showed no change; only two were negative.
Ferrara M, Bertozzi G, Di Fazio N, et al. Healthcare (Basel). 2024;12:549.
Artificial intelligence (AI) is being rapidly integrated into clinical care and research. This review summarizes how AI can be used to prevent adverse events (e.g., medication errors) and improve the efficiency of incident reporting systems through natural language processing and machine learning.
Chong RIH, Yaow CYL, Chong NZ-Y, et al. Am J Surg. 2024;229:5-14.
Healthcare providers and staff who are involved in an adverse patient event may experience negative emotional consequences known as "second victim syndrome" (SVS). This scoping review highlights SVS experienced by surgeons, categorized into psychological, physical, and professional impacts, and describes the factors that support or hinder their recovery.
Canfell OJ, Woods L, Meshkat Y, et al. J Med Internet Res. 2024;26:e47715.
Electronic health records (EHR) and health information technology are nearly ubiquitous in hospitals. This review describes patient and clinician experience with digital hospitals (i.e., EHR).  Despite generally positive experiences, clinicians still report tensions and uncertainties (e.g., privacy) around the technology, and additional efforts should be made to alleviate these concerns.
Ruutiainen H, Holmström A-R, Kunnola E, et al. Pediatr Drugs. 2024;26:127-143.
Computerized provider order entry (CPOE) and clinical decision support (CDS) are widely used tools to help improve safe prescribing practices. This systematic review of 17 studies examined the impact of CPOE systems with CDS in preventing pediatric medication dosing errors. Included studies evaluated CDS tools providing dose range checks, dose calculators, and dosing frequency checks. The majority of studies reported improvements in dose error prevention with use of CPOE-CDS systems, with eight studies reporting significant reductions in dosing errors.
No results.

Clark C. MedPage Today. March 14, 2024.

Stories from clinicians involved in errors provide unique insights into both the human and system weaknesses contributing to failure. This article summarizes a presentation by a nurse charged criminally after a medication mistake, her memory of what occurred and how she managed the situation, and relationship with the family after her sentencing.

Ruskin KJ, ed. Int Anesthesiol Clin. 2024;62(2):1-65.

Anesthesia is a vital component of surgical care that can be compromised due to human and equipment factors. This special issue highlights a range of topics exploring Safety II, safety culture implementation, and artificial intelligence applications as they affect safe anesthesia provision in the operating room.

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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