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April 10, 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

Sherbino J, Sibbald M, Norman GR, et al. BMJ Qual Saf. 2024;Epub Mar 19.
Collaboration between clinicians encourages better diagnostic decision making and clinical outcomes. This study sought to determine if collaboration improves diagnostic accuracy, assessing by collaborative group size (3 or 6 physicians) and process type (interactive or retrospective). Groups had better diagnostic accuracy than individuals, regardless of group size. Process types were equally effective.
Li L, Baker J, Quirk R, et al. Drug Saf. 2024;47:557-569.
Drug-drug interactions (DDI) can be harmful. This study examined frequency of potential DDI (pDDI) and clinically relevant DDI (cDDI) in three hospitals both before and after implementation of an electronic medication management (EMM) system, without accompanying decision support alerts. The frequency of pDDI and cDDI orders did not differ between timeframes, although the likelihood of both drugs being co-administered was lower post-EMM implementation. Only one-quarter of pDDI were clinically relevant, and actual harm was less than 1% in both timeframes and was primary mild. Given the low prevalence of actual harm and the decreased likelihood of co-administration of drugs even without alerts, caution should be used when implementing DDI alerts so as not to introduce alert fatigue.
Tang KM, Lee P, Anosike BI, et al. Hosp Pediatr. 2024;14:281-290.
Antimicrobial stewardship programs (ASPs) can reduce antimicrobial prescribing errors. In this quality improvement study, researchers implemented a standardized workflow intended to reduce prescribing errors among pediatric patients on ASP-restricted medication courses (e.g., vancomycin, levofloxacin). Workflow interventions included ASP education, a pharmacy standardized operating procedure, best practice advisory in the electronic health record (EHR), and an EHR-generated list of patients on ASP-restricted medications. After implementation, ASP prescribing errors decreased from 10.9% to 4.6%.
Kinlay M, Zheng WY, Burke R, et al. J Patient Saf. 2024;20:202-208.
Deployment of electronic health records, including electronic medication management (EMM) systems, can resolve some errors (e.g., transcription errors) while introducing new ones. This study analyzed types of incident reports related to EMM at three hospitals over the course of its implementation. Errors were categorized by EMM design, user conditions (e.g., unfamiliarity with EMM workflow), and organization conditions (e.g., simultaneous use of paper and EMM documentation). These errors persisted despite time since EMM implementation, suggesting ongoing training and system maintenance is required.
Sherbino J, Sibbald M, Norman GR, et al. BMJ Qual Saf. 2024;Epub Mar 19.
Collaboration between clinicians encourages better diagnostic decision making and clinical outcomes. This study sought to determine if collaboration improves diagnostic accuracy, assessing by collaborative group size (3 or 6 physicians) and process type (interactive or retrospective). Groups had better diagnostic accuracy than individuals, regardless of group size. Process types were equally effective.
Tang KM, Lee P, Anosike BI, et al. Hosp Pediatr. 2024;14:281-290.
Antimicrobial stewardship programs (ASPs) can reduce antimicrobial prescribing errors. In this quality improvement study, researchers implemented a standardized workflow intended to reduce prescribing errors among pediatric patients on ASP-restricted medication courses (e.g., vancomycin, levofloxacin). Workflow interventions included ASP education, a pharmacy standardized operating procedure, best practice advisory in the electronic health record (EHR), and an EHR-generated list of patients on ASP-restricted medications. After implementation, ASP prescribing errors decreased from 10.9% to 4.6%.
Breathett K, Knapp SM, Lewsey SC, et al. JAMA. 2024;331:1379-1386.
Implicit bias can impact how long a patient waits for appropriate treatment. This study used heart transplant data from United Network for Organ Sharing (UNOS) to determine how many offers of donor hearts a transplant treatment team declined, if any, before accepting a donation on behalf of their patient. White women were consistently more likely to get an acceptance at the first offer (i.e., the transplant team did not decline any offers before accepting); Black men generally had to wait the longest before an offer was accepted.
Li L, Baker J, Quirk R, et al. Drug Saf. 2024;47:557-569.
Drug-drug interactions (DDI) can be harmful. This study examined frequency of potential DDI (pDDI) and clinically relevant DDI (cDDI) in three hospitals both before and after implementation of an electronic medication management (EMM) system, without accompanying decision support alerts. The frequency of pDDI and cDDI orders did not differ between timeframes, although the likelihood of both drugs being co-administered was lower post-EMM implementation. Only one-quarter of pDDI were clinically relevant, and actual harm was less than 1% in both timeframes and was primary mild. Given the low prevalence of actual harm and the decreased likelihood of co-administration of drugs even without alerts, caution should be used when implementing DDI alerts so as not to introduce alert fatigue.
Patel K, Smith DJ, Huntley CC, et al. PLoS ONE. 2024;19:e0298432.
Misdiagnosis can lead to delayed or unnecessary treatment and threaten patient safety. This mixed methods study examined the prevalence and features of patients misdiagnosed with chronic obstructive pulmonary disease (COPD). Among 1,458 patients, researchers found that 14% had been misdiagnosed with COPD, primarily due to challenges interpreting spirometry reports or misinterpretation of clinical history.
Gupta AB, Flanders SA, Petty LA, et al. JAMA Intern Med. 2024;184:548-556.
Misdiagnosis may delay appropriate treatment and/or result in improper treatment. In this study of more than 17,000 patients with a discharge diagnosis of community-acquired pneumonia (CAP), 12% did not meet the diagnostic criteria. 25% of inappropriately diagnosed patients experienced an antibiotic-associated adverse event. Older adults, those with dementia, and those presenting with altered mental status were more likely to be inappropriately diagnosed.
Schneider K, Williams M, Mohr NM, et al. Prehosp Emerg Care. 2024;28:735-744.
Feedback is a core component of performance improvement and patient safety efforts. This qualitative study with rural EMS clinicians and administrative staff highlights the importance of consistent, organized clinical feedback from hospitals to EMS personnel in order to improve care delivery, interprofessional relationships, and professional development.
Rosen AK, Beilstein-Wedel E, Chan J, et al. Jt Comm J Qual Patient Saf. 2024;50:247-259.
Event reporting is an essential component of patient safety improvement efforts. This retrospective study compared patient safety event incidents reported in Veterans Health Administration (VHA) and community care (CC) settings during the COVID-19 pandemic (2020-2022). The researchers identified fluctuations in safety event reporting over the study period, which may be attributable to disruptions in care introduced by the pandemic such as burnout or resource challenges, as well as preexisting organizational factors (e.g., safety practices, safety culture, reporting behaviors).
Minartz P, Aumann CM, Vondeberg C, et al. Syst Rev. 2024;13:62.
As more and more digital technologies are relied upon in healthcare, understanding patient and provider perceived safety is increasingly important. This scoping review highlights perceived safety of digital technology at the individual, community/organization, and societal/system levels. Unsurprisingly, strong perceived safety increased the acceptance of digital technologies and lower perceived safety decreased acceptance. Strong perceived safety also resulted in overreliance on technology, resulting in lack of attention. Perceived safety in the context of ethics, economics, transparency, and more are also discussed.
Freedman B, Li WW, Liang Z, et al. J Adv Nurs. 2024;Epub Mar 21.
Workplace incivility is known to decrease patient safety culture. This review identified 41 studies on workplace incivility experienced or witnessed by hospital healthcare providers, its association with safety culture and patient outcomes, and mediating factors. Meta-analysis results indicate 25% of healthcare providers experience incivility and 30% witness incivility. Incivility was associated with near misses, adverse events, and mortality.
No results.

Neergaard L. Associated Press. April 1, 2024.

Historical medical racism continues to harm patients today. This article discusses the racism built into the kidney function algorithm that was used to determine eligibility for a kidney transplant and how transplant centers are working to correct that wrong.

Washington, DC: The Veterans Affairs Inspector General; March 21, 2024. Report No. 23-01450-114.

Although electronic health record (EHR) systems can promote patient safety, its implementation can also introduce safety concerns. This investigation from the VA (Veterans Administration) Office of Inspector General (OIG) examined pharmacy-related patient safety concerns (such as prescription backlogs) after implementation of a new EHR system in one VA healthcare system.

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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