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April 24, 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

Bradford A, Meyer AND, Khan S, et al. BMJ Qual Saf. 2024;Epub Apr 4.
Diagnostic errors in mental health disorders have not yet received the same attention as diagnostic errors in other care settings. This article describes diagnostic pitfalls for common mental health disorders including schizophrenia, anxiety, attention deficit hyperactivity (ADHD), autism spectrum, mood, and bipolar disorders. The authors urge parallel development of interventions to reduce misdiagnosis and estimating error rates.
Forbes J, Arrieta A. BMJ Lead. 2024;Epub Apr 3.
Front-line workers (e.g., nurses and physicians) and leaders frequently perceive the safety culture in their organization differently. This study uses data from AHRQ’s Hospital Survey on Patient Safety Culture (HSOPS) V.1.0 from 2008 - 2017 to compare leadership and front-line workers' perceptions of patient safety culture. With responses from 1,810 hospitals and more than 800,000 individuals identified as leaders or front-line workers, results show that leadership has a consistently more positive perception of patient safety culture, particularly on items related to managers.
Slawomirski L, Hensher M, Campbell JL, et al. Health Policy. 2024;143:105051.
Pay-for-performance (P4P) policies and programs (such as the Hospital-Acquired Condition [HAC] Reduction Program) intend to incentivize high-quality care and reduce medical errors. This systematic review including 53 articles explored the impact of P4P on the incidence of adverse events in acute care settings. The researchers found that half of the included studies did not identify improvements in adverse event rates after P4P, and that studies reporting improvements were of poor methodological quality.
Forbes J, Arrieta A. BMJ Lead. 2024;Epub Apr 3.
Front-line workers (e.g., nurses and physicians) and leaders frequently perceive the safety culture in their organization differently. This study uses data from AHRQ’s Hospital Survey on Patient Safety Culture (HSOPS) V.1.0 from 2008 - 2017 to compare leadership and front-line workers' perceptions of patient safety culture. With responses from 1,810 hospitals and more than 800,000 individuals identified as leaders or front-line workers, results show that leadership has a consistently more positive perception of patient safety culture, particularly on items related to managers.
Franco Vega MC, Ait Aiss M, George M, et al. Jt Comm J Qual Patient Saf. 2024;Epub Mar 8.
The I-PASS tool has been implemented in a variety of healthcare settings to improve communication during patient handoffs. This article describes the implementation of an electronic health record (EHR)-based I-PASS tool used to standardize handoff documentation among fellows, residents, advanced practice providers (APPs) and physician assistants (PAs) at one Comprehensive Cancer Center. After I-PASS training, tool adherence improved from 42% to 71% and perceived handoff scores improved on safety culture surveys.
Jallow F, Stehling E, Sajwani-Merchant Z, et al. J Patient Saf. 2024;20:192-197.
There are available guidelines for older adults on how to take their medications safely, and how closely older adults' actual medication management practices align to guidelines is an important area of study. This study asked 28 community-dwelling older adults taking five or more medications how they manage them, and compared those strategies to the Food and Drug Administration (FDA) and National Institute on Aging (NIA) guidelines. Several strategies were in opposition to the guidelines, including self-weaning or splitting pills. Additionally, several reported seeking information from potentially unsafe sources (e.g., internet).
Balanean A, Bland E, Gajra A, et al. J Natl Compr Canc Netw. 2024;22:82-90.
Racism and implicit bias can result in poorer health outcomes for patients of color. This study examined racial disparity, racial anxiety, and physician unconscious bias and adverse influence on outcomes of non-white oncology patients. Nearly two-thirds of oncologists perceived moderate to very high levels of racial disparities, and a similar proportion rarely or never perceived unconscious bias having a negative influence on patient outcomes.
Shehab N, Alschuler L, McILvenna S, et al. J Am Med Inform Assoc. 2024;31:1199-1205.
The National Healthcare Safety Network (NHSN) tracks healthcare-associated infections as well as improvement efforts. This article describes NHSN use of digital quality measures (dQMs) and other online resources to reduce the reporting burden and improve the quality of surveillance data.
No results.
Bradford A, Meyer AND, Khan S, et al. BMJ Qual Saf. 2024;Epub Apr 4.
Diagnostic errors in mental health disorders have not yet received the same attention as diagnostic errors in other care settings. This article describes diagnostic pitfalls for common mental health disorders including schizophrenia, anxiety, attention deficit hyperactivity (ADHD), autism spectrum, mood, and bipolar disorders. The authors urge parallel development of interventions to reduce misdiagnosis and estimating error rates.
Scanlan R, Flenady T, Judd J. J Adv Nurs. 2024;Epub Mar 30.
Healthcare facilities are routinely subjected to accreditation processes to ensure the delivery of evidence-based care. This scoping review examined whether limited advanced warning of an impending accreditation process can impact quality patient safety, but failed to identify any studies evaluating this relationship.
Slawomirski L, Hensher M, Campbell JL, et al. Health Policy. 2024;143:105051.
Pay-for-performance (P4P) policies and programs (such as the Hospital-Acquired Condition [HAC] Reduction Program) intend to incentivize high-quality care and reduce medical errors. This systematic review including 53 articles explored the impact of P4P on the incidence of adverse events in acute care settings. The researchers found that half of the included studies did not identify improvements in adverse event rates after P4P, and that studies reporting improvements were of poor methodological quality.
Kassie AM, Eakin E, Abate BB, et al. BMC Health Serv Res. 2024;24:438.
Positive deviance (PD) in healthcare is an approach to learn from individuals or groups who are performing well above the norm in similar circumstances. This review identified 125 articles on PD. Studies focused on a variety of challenges such as hand hygiene and healthcare-associated infections. Before researchers and leaders embark on learning from positive deviants, a clear definition of PD and relevant performance measures must be identified.
Mira JJ, Matarredona V, Tella S, et al. BMC Med Educ. 2024;24:378.
Similarly to practicing providers, medical and nursing students can experience second victim syndrome. This review sought to learn about if and how students are taught about second victims and what types of support are offered to them following an adverse event. The authors suggest that instruction about second victims could be included in curriculum on identifying errors.
Peng M, Saito S, Mo W, et al. Jpn J Nurs Sci. 2024;21:e12578.
Missed nursing care is an indicator of poor quality. This review synthesizes what causes missed nursing care. The causes were grouped into three main themes: intrinsic resources, system structure, and social environment. The review also presents nurses' strategies to overcome challenges such as incorporating informal teaching into every patient interaction.
No results.

Washington, DC: United States Government Accounting Office; April 11, 2024. Publication GAO-24-106107.

Health care organizations are expected to examine known practice concerns to determine what provider-focused actions need to be undertaken. This report summarizes findings from 55 case reports at military care facilities to identify investigation process weaknesses and submit recommendations for improvement. They found the timeliness of problem reporting and facility-centric actions to resolve identified issues were substandard.
Special or Theme Issue

Cadwallader AB, ed. AMA J Ethics. 2024;26(4):e275-e359.

Drug shortages are a known problem that gained patient safety prominence during the COVID-19 pandemic. This special issue covers a range of systemic considerations toward building the resilience of the medication supply operation to ensure safe, equitable access to pharmaceutical agents and other medical supplies.

Dorset, UK: Health Services Safety Investigations Body; 2024.

The complex health care work environment creates conditions that detract from staff ability to provide safe care. This collection of reports to be developed and distributed over the course of 2024 will cover workforce challenges that can affect the safety of patients and provide recommendations for improvement. The first report in the series, which focuses on temporary staff involvement in patient safety investigations, is now available.

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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