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April 3, 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

Gonzalez CM, Ark TK, Fisher MR, et al. JAMA Netw Open. 2024;7:e242181.
Clinicians' implicit racial bias can result in poor communication, poor patient care, and patients not returning for follow up. In this study, physicians participated in a simulated online patient visit, randomized to either a Black or white standardized patient (SP). Both the physician and SP were blinded to the true purpose of the study, which was to explore the association between the physician's implicit bias and the SP's rating of the physician's communication skills. Results show a significant association between physician bias and communication scores.
Kwan JL, Calder LA, Bowman CL, et al. Can J Surg. 2024;67:e58-e65.
Research into diagnostic errors frequently focuses on hospitals, emergency departments, and primary care, with less focus on surgical diagnostic errors. This study used medico-legal cases and complaints to characterize surgical diagnostic errors. Most errors occurred post-operatively (e.g., failure to recognize clinical deterioration) and were attributed to providers’ clinical decision-making.
Wash A, Moczygemba LR, Brown CM, et al. J Am Pharm Assoc (2003). 2023;64:337-349.
Improving healthcare provider well-being and reducing burnout is a focus of many patient safety efforts. This narrative review highlights research into well-being and burnout in community pharmacists, a segment of the healthcare workforce that was experiencing high rates of stress even before the pandemic. Despite many studies measuring community pharmacist burnout, there were no studies identified into interventions or strategies to improve well-being or reduce burnout.
Kwan JL, Calder LA, Bowman CL, et al. Can J Surg. 2024;67:e58-e65.
Research into diagnostic errors frequently focuses on hospitals, emergency departments, and primary care, with less focus on surgical diagnostic errors. This study used medico-legal cases and complaints to characterize surgical diagnostic errors. Most errors occurred post-operatively (e.g., failure to recognize clinical deterioration) and were attributed to providers’ clinical decision-making.
Recsky C, Rush KL, MacPhee M, et al. JMIR Form Res. 2024;8:e53302.
Health information technology (HIT) can increase the safety of many processes, but it may also introduce new challenges. In this study, a researcher was embedded in a clinical informatics team to explore their longitudinal experience of incorporating safety and safety culture into their work. Individual outcomes included a sense of ownership of HIT safety, and team outcomes included improved safety culture and curiosity of errors instead of blaming the user.
Mattay G, Mallikarjun K, Grow P, et al. J Patient Saf. 2024;Epub Mar 18.
Patients typically receive numerous laboratory and imaging studies while hospitalized, some of which may have findings unrelated to the primary reason for admission (i.e., incidental findings), which must be communicated to patients. In this study, records of patients with incidental imaging findings (IIF) were reviewed to determine if IIFs were included on hospital discharge summaries and if the patients were aware of them. Approximately half of discharge summaries mentioned IIFs, and most patients and providers (79%) were aware of the findings.
Farag A, Gallagher J, Carr L. West J Nurs Res. 2024;46:288-295.
Healthcare provider fatigue has been associated with adverse events such as medication errors. This study examines the association of fatigue and alertness with medication errors and near misses in hospital nurses. Alertness was continuously measured via a wearable sleep and activity monitor (actigraph), and fatigue was self-reported with ecological momentary assessments via text messages. Nurse fatigue, but not alertness, was associated with self-reported medication errors and near misses.
Molloy L, Wilson V, O'Connor MF, et al. Int J Ment Health Nurs. 2024;Epub Feb28.
Patient safety and safety culture in psychiatric settings is an emerging focus for patient safety researchers. This observational study found that patients experienced boredom throughout the day, as nursing staff were frequently occupied with administrative tasks, leaving little time for patient engagement. Implementing a culture of engagement across the organization may improve patient recovery and overall safety culture.
Furthmiller A, Sahay R, Zhang B, et al. J Hosp Med. 2024;19:589-595.
Even with extensive planning and simulations, relocating or opening a new unit can present unanticipated patient safety challenges. This study describes the quantity, rate, severity score, and category of safety events submitted in the 90 days before and after relocation of the pediatric, cardiac, and neonatal intensive care units of one hospital. There were no statistically significant changes in severity of safety events before and after relocation, and only two categories of events showed statistically significant changes in quantity of reported events.
Staal J, Katarya K, Speelman M, et al. Adv Health Sci Educ Theory Pract. 2024;29:129-145.
Calibration is the alignment of between a clinician’s perceived and actual diagnostic accuracy. In this randomized study, pre-clerkship medical students diagnosed chest x-rays and rated their confidence in the diagnosis. The control group received no feedback, one group received performance (accuracy) feedback, and one group received additional information on why the diagnosis was correct or not. Students in both intervention groups showed increased confidence, accuracy, and calibration in comparison to those in the control group. These results suggest feedback is an effective method to improve calibration.
Gonzalez CM, Ark TK, Fisher MR, et al. JAMA Netw Open. 2024;7:e242181.
Clinicians' implicit racial bias can result in poor communication, poor patient care, and patients not returning for follow up. In this study, physicians participated in a simulated online patient visit, randomized to either a Black or white standardized patient (SP). Both the physician and SP were blinded to the true purpose of the study, which was to explore the association between the physician's implicit bias and the SP's rating of the physician's communication skills. Results show a significant association between physician bias and communication scores.
Kopanz J, Lichtenegger K, Schwarz CM, et al. PLoS ONE. 2024;19:e0297491.
Medication errors can occur at any step along the medication pathway. This study sought to identify critical risks and solutions in analog (pathway including at least one non-digital step) and fully digital medication processes. In both processes, experts identified that the most critical risk of errors and harm occurs at admission, in prescribing, and during preparation and dispensing of medication. Solutions for improving analog methods focused on strengthening healthcare professional competence; digital solutions included digital medication lists with automated alerts.
Vandeskog B. J Safety Res. 2024;89:105-115.
Safety is at the heart of safety science, and yet “safety” lacks a consensus definition among safety researchers. This article proposes a new concept of safety as the preservation of values/valuables, experiences, and objects. As such, the author asserts that future safety research, including patient safety, must begin by clearly defining and identifying the valuables at stake.
Croke L. AORN J. 2024;119:7-10.
Clinicians involved in medical errors can be psychologically affected by the experience and they can benefit from the assistance of others to heal. This commentary shares strategies for organizations to facilitate recovery for these individuals, building on a just culture including counseling services and peer support.
Wash A, Moczygemba LR, Brown CM, et al. J Am Pharm Assoc (2003). 2023;64:337-349.
Improving healthcare provider well-being and reducing burnout is a focus of many patient safety efforts. This narrative review highlights research into well-being and burnout in community pharmacists, a segment of the healthcare workforce that was experiencing high rates of stress even before the pandemic. Despite many studies measuring community pharmacist burnout, there were no studies identified into interventions or strategies to improve well-being or reduce burnout.
Saif S, Bui TTT, Srivastava G, et al. Syst Rev. 2024;13:12.
Medication labels can be confusing to patients, leading to errors, incorrect usage, and early discontinuation of the drug. This review highlights how patient-centered design of medication labels can improve patient comprehension, safe usage, and adherence. Future research should focus on standardization, evaluation, and validation of content and display.
No results.

Paris, France: OECD Publishing; 2024.

There are substantive challenges to the implementation and use of artificial intelligence (AI) to support safe, equitable health care delivery. This report outlines opportunities and hazards associated with AI worldwide and suggests policy approaches to enabling its effective use.

ISMP Medication Safety Alert! Acute Care. 2024;29(6):1-4.

Systemic failures can perpetuate unsafe care if a lack of prioritization distracts from efforts to address them. This article aims to renew attention to parenteral syringe misuse, clinical resource shortages, and barcode scanning workaround acceptance as key contributors to medication error and provides recommendations to reduce risk in these three areas.

This Month’s WebM&Ms

WebM&M Cases
Anita Singh, MD and Cecilia Huang, MD |
An 82-year-old woman presented to the emergency department for evaluation of “altered mental status” after falling down 5 step-stairs at home. She had a Glasgow Coma Score of 11 (indicating decreased alertness) on arrival. Computed tomography (CT) of the head revealed a right thalamic hemorrhage. She was admitted to the Vascular Neurology service. Overnight, the patient developed atrial fibrillation with rapid ventricular rate (RVR), which required medications for rate control. The patient failed her swallow evaluation by speech therapy; therefore, a nasogastric (NG) tube was inserted through her right nostril, without difficulty or complications, to administer oral medications. A chest radiograph was obtained to verify placement, but the resident physician did not review the images. During nursing shift change, the incoming nurse was told that the NG tube was ready for use. A tablet of metoprolol 25 mg was crushed by the nurse, mixed with water, and administered through the NG tube. A few minutes after administration, the patient was found to be somnolent and hypoxemic, with oxygen saturation around 80%, requiring supplemental oxygen via non-rebreather mask. Chest radiography showed that the NG tube was in the right lung. The commentary underscores the importance of confirming proper placement of NG tubes before administering feedings, fluids or medications and strategies to reduce the risk of tube placement errors.
WebM&M Cases
Spotlight Case
Eric Signoff, MD, Noelle Boctor, MD, and David K. Barnes, MD, FACE |
A 61-year-old patient presented to the emergency department (ED) complaining of weakness with findings of shuffling gait, slurred speech, delayed response to questions, and inability to concentrate or make eye contact. A stroke alert was activated and a neurosurgeon evaluated the patient via teleconsult. There was no intracranial hemorrhage identified on non-contrast computed tomography (CT) of the head and the neurosurgeon recommended administering Tenecteplase (TNKase). Thirty minutes after TNKase administration, laboratory tests showed that the patient’s alcohol level was 433 mg/dL, a potentially fatal level. The patient was admitted to the intensive care unit (ICU) for close monitoring. A repeat CT scan was performed and revealed a new subdural hemorrhage. The neurosurgeon was updated, conservative treatment was recommended, and the patient recovered slowly. The commentary highlights how “stroke chameleons,” “stroke mimics,” and biases contribute to stroke misdiagnosis and strategies to identify “stroke mimics” and improve stroke diagnosis.
WebM&M Cases
David K. Barnes, MD, FACEP, Sahej Deep Singh Randhawa, MD, and Ellen P. Fitzpatrick, MD |
This pair of cases highlight the immediate and long-term consequences of delayed recognition of compartment syndrome, despite patients presenting with symptoms such as severe pain, numbness, and swelling in the affected limbs. The commentary discusses the importance of a multifactor assessment when compartment syndrome is suspected, effective processes for trainees and non-physician staff to escalate concerns to attending physicians when compartment syndrome is suspected, and improving post-discharge follow-up practices to identify patients requiring further evaluation.

This Month’s Perspectives

Katie Boston-Leary headshot
Interview
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCT |
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCT, is the Director of Nursing Programs at the American Nurses Association and Adjunct Professor at the University of Maryland School of Nursing and the Frances Payne Bolton School of Nursing at Case Western Reserve University. We spoke to her about patient safety amid nursing workforce challenges.
Perspective
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD |
This piece focuses on changes in the nursing workforce over recent years, including nursing shortages. Patient safety challenges may arise from these workforce challenges, but those challenges can also be mitigated.
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