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April 17, 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

Brewer A, Hughes MC, Patel KN. J Patient Saf. 2024;20:198-201.
The Hospital-Acquired Condition (HAC) Reduction Program (HACRP) assesses penalties on hospitals with high rates of HAC. This study explores the impact of repeated HACRP penalties on hospital improvement and variation by hospital characteristics. When considering all hospitals, repeated HACRP penalties resulted in improved HAC scores. Hospitals with disproportionate shares of Medicare and Medicaid patients showed less improvement; the researchers note that the differential improvement may be due to resource limitations at hospitals serving vulnerable populations (i.e., Medicare and Medicaid patients).
Chen F, Wang L, Hong J, et al. J Am Med Inform Assoc. 2024;31:1172-1183.
When biased data are used for research, the results may reflect the same biases if appropriate precautions are not taken. In this systematic review, researchers describe possible types of bias (e.g., implicit, selection) that can result from research with artificial intelligence (AI) using electronic health record (EHR) data. Along with recommendations to reduce introducing bias into the data model, the authors stress the importance of standardized reporting of model development and real-world testing.
Post W, Thomas AD, Sutton KM. Birth. 2024;Epub Apr 2.
Structural racism and discrimination can impede safe maternal care. This qualitative study among Black women highlighted how their severe maternal morbidity (SMM) experiences relate to manifestations of racism through communication failures and stereotyping, differential treatment, and medical errors/near misses.
Post W, Thomas AD, Sutton KM. Birth. 2024;Epub Apr 2.
Structural racism and discrimination can impede safe maternal care. This qualitative study among Black women highlighted how their severe maternal morbidity (SMM) experiences relate to manifestations of racism through communication failures and stereotyping, differential treatment, and medical errors/near misses.
Murphy DR, Kadiyala H, Wei L, et al. J Telemed Telecare. 2024;Epub Apr 1.
The expansion of telehealth has improved access to care, but concerns have been raised about potential for diagnostic errors. In this study, researchers used the Safer Dx Trigger tool framework to develop an electronic trigger to identify delayed diagnoses during primary care telehealth visits at a Veterans Health Affairs (VHA) facility. Applying the trigger tool to a random sample of 100 telehealth visits with a subsequent unplanned visit (emergency department, hospital or primary care) yielded a positive predictive value of 11%.
Sokol-Hessner L, Dechen T, Folcarelli P, et al. Jt Comm J Qual Patient Saf. 2024;Epub Mar 7.
Medical errors can cause physical, financial, or emotional harm to patients. This survey identified prolonged emotional impacts (greater than one year) among the majority of US adults who experienced a medical error. Survey respondents who were female or with a lower socioeconomic status were more likely to report prolonged emotional impacts; organizational factors such as lack of organizational disclosure guidelines and no patient or family reporting process also increased risk of prolonged emotional impacts.
Cabral S, Restrepo D, Kanjee Z, et al. JAMA Intern Med. 2024;184:581-583.
Research into how large language models (LLM) such as ChatGPT can be used in healthcare is growing rapidly. This study compared ChatGPT and physicians' clinical reasoning in a simulated case study. Using the validated Revised-IDEA (R-IDEA) framework, the LLM performed better than physicians did in processing medical data and clinical reasoning; there were no differences observed using other frameworks.
Camacho EM, Gavan S, Keers RN, et al. BMJ Qual Saf. 2024;Epub Mar 26.
Transitions of care introduce risk of medication errors, even with interoperable electronic medication systems; systems that do not communicate with each other introduce even more risk. This study estimates the prevalence and burden of medication errors at transitions of care (hospital admission, hospital discharge, transfers between hospitals, and transfers within hospitals) when electronic medication records are not interoperable. Implementing interoperable prescribing systems could significantly reduce the number of errors and prevent medication error-related patient deaths.
Brewer A, Hughes MC, Patel KN. J Patient Saf. 2024;20:198-201.
The Hospital-Acquired Condition (HAC) Reduction Program (HACRP) assesses penalties on hospitals with high rates of HAC. This study explores the impact of repeated HACRP penalties on hospital improvement and variation by hospital characteristics. When considering all hospitals, repeated HACRP penalties resulted in improved HAC scores. Hospitals with disproportionate shares of Medicare and Medicaid patients showed less improvement; the researchers note that the differential improvement may be due to resource limitations at hospitals serving vulnerable populations (i.e., Medicare and Medicaid patients).
Sutherland AB, Phipps DL, Grant S, et al. Ergonomics. 2024;Epub Apr 1.
Medication errors are often the result of both individual failures and system flaws. This qualitative study found that medication safety practices in pediatric inpatient units are often hindered by issues in the physical environment (e.g., workspace layouts, interruptions) and by poorly integrated workflows.
Crowe L, Riley CM. Curr Opin Cardiol. 2024;39:331-337.
Unprofessional behavior negatively impacts the work environment, team functioning, and patient safety. Women, minoritized, and junior staff are more likely to be the targets of unprofessional behavior and are less likely to report it due to fear of retaliation or thinking nothing will be done to curb the perpetrator's behavior. Clear and consistent organizational commitment to address unprofessional behavior can mediate many of the negative patient safety impacts.
Montgomery A, Lainidi O, Georganta K. Healthcare (Basel). 2024;12:635.
A strong safety culture relies on staff formally reporting or speaking up about adverse events (AE), yet valid reasons exist to explain why staff may choose not to. This article argues that although staff may not be using formal channels to report AE, they are engaging in informal communication. Using high-profile adverse events, the authors describe the important role gossip plays in sense-making and how leadership would do well to listen to this informal communication.
Strandås M, Vizcaya-Moreno M, Ingstad K, et al. J Multidiscip Healthc. 2024;17:1385-1400.
Paramedics often provide critical medical care during complex, high-stress scenarios. This systematic review of 16 studies found that paramedics encounter a myriad of challenges in maintaining safe patient care (e.g., uncertainties about role expectations, insufficient resources). Studies highlighted the effectiveness of interventions to increase technical and non-technical skills and improve communication and collaboration to promote patient safety.
Hults CM, Ding Y, Xie GG, et al. Cogn Res Princ Implic. 2024;9:18.
Inattentional blindness occurs when a person is focused so intently on one task that they miss other important information. This review identifies studies of inattentional blindness in healthcare, from radiology to surgery to nursing. The authors make recommendations on how to improve designing and reporting studies of inattentional blindness.
Chen F, Wang L, Hong J, et al. J Am Med Inform Assoc. 2024;31:1172-1183.
When biased data are used for research, the results may reflect the same biases if appropriate precautions are not taken. In this systematic review, researchers describe possible types of bias (e.g., implicit, selection) that can result from research with artificial intelligence (AI) using electronic health record (EHR) data. Along with recommendations to reduce introducing bias into the data model, the authors stress the importance of standardized reporting of model development and real-world testing.
No results.

Manchester, UK: Parliamentary and Health Service Ombudsman; March 2024.

The provision of safe mental health care is receiving increased attention as an area of concern. This report examined six incidents of poor discharge care for patients with mental health conditions. The authors highlight system issues exacerbating the failures discussed and provide recommendations for improvement.

ISMP Medication Safety Alert! Acute care. April 4, 2024;29(7):1-4.

Safe medication therapy for transplant patients is complex and has the potential for serious harm when errors occur. This article reports on an analysis of 520 transplant medication-related errors to summarize the types of mistakes that occurred, and to provide suggestions for improvement that emphasize medication reconciliation, order set development, and clinical decision support use.

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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