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May 1, 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

Marsh KM, Turrentine FE, Jin R, et al. J Am Coll Surg. 2024;238:874-879.
Knowing when judgment errors are more likely to occur can increase surgeons' awareness before, during, and after procedures. This study examined the records of 131 patients with 30-day morbidity or mortality to identify any errors in judgment that may have contributed to harm. Examples of errors in judgment included inappropriate operation, premature discharge, and premature removal of drain. Most errors occurred post-operatively (including after discharge) and in colorectal and hepatobiliary procedures.
McMullan RD, Churruca K, Hibbert P, et al. Int J Qual Health Care. 2024;36:mzae030.
Unprofessional behavior negatively impacts teamwork, safety culture, and patient safety. This study analyzed 1,310 reports of unprofessional behavior across eight Australian hospitals between 2017-2020. The researchers found that three in ten reports indicated a risk to patient safety, such as interruptions, poor handover communication, and a lack of adherence to hospital policy or protocol.
Müller BS, Lüttel D, Schütze D, et al. J Patient Saf. 2024;Epub Mar 18.
Patient safety in ambulatory care settings is receiving increasing attention. This study evaluated an error management and safety climate intervention implemented across 184 ambulatory practices in Germany. The intervention included email newsletters on error management, e-learning modules to improve team engagement, and interdisciplinary workshops to discuss critical incidents. Survey feedback identified significant improvements in safety climate as well as improvements to incident reporting and learning systems.
McMullan RD, Churruca K, Hibbert P, et al. Int J Qual Health Care. 2024;36:mzae030.
Unprofessional behavior negatively impacts teamwork, safety culture, and patient safety. This study analyzed 1,310 reports of unprofessional behavior across eight Australian hospitals between 2017-2020. The researchers found that three in ten reports indicated a risk to patient safety, such as interruptions, poor handover communication, and a lack of adherence to hospital policy or protocol.
Bursch B, Ziv K, Marchese S, et al. Jt Comm J Qual Patient Saf. 2024;50:442-448.
Peer support is a common component of second victim support programs. This study describes second victims' experiences of organizational emotional support before and after introduction of a skilled peer support program (SPSP). Respondents reported that institutional support had increased; they felt like the organization learned from the adverse event to prevent it from recurring.
Ambrose JW, Catchpole K, Evans HL, et al. BMC Health Serv Res. 2024;24:459.
COVID-19 brought unprecedented challenges to healthcare teams. This study describes factors that contributed to or detracted from healthcare team resiliency. Participants reported increased team cohesion and shared responsibility while also describing the environment as a "pressure cooker." There were also difficulties stemming from gaps in knowledge of reassigned staff, for example, pediatric nurses reassigned to adult wards. 
Marsh KM, Turrentine FE, Jin R, et al. J Am Coll Surg. 2024;238:874-879.
Knowing when judgment errors are more likely to occur can increase surgeons' awareness before, during, and after procedures. This study examined the records of 131 patients with 30-day morbidity or mortality to identify any errors in judgment that may have contributed to harm. Examples of errors in judgment included inappropriate operation, premature discharge, and premature removal of drain. Most errors occurred post-operatively (including after discharge) and in colorectal and hepatobiliary procedures.
Edfeldt K, Nyholm L, Jangland E, et al. BMC Nurs. 2024;23:233.
Missed nursing care (MNC) is an indicator of poor quality. This study surveyed nursing assistants (NA) and registered nurses (RN) in three surgical wards in Sweden about the types of and factors associated with MNC. The most frequently missed tasks, reported by both RNs and NAs, included not attending interdisciplinary care conferences and not performing ambulation three times per day. Nearly a quarter of RNs and NAs intended to leave within the year. Given the most frequently endorsed reason for missed nursing care is understaffing, and that a quarter of staff intend to leave within the year, interventions aimed at reducing nurse turnover may reduce missed nursing care.
Li L, Badgery-Parker T, Merchant A, et al. BMJ Qual Saf. 2024;Epub Apr 15.
Errors and near misses reported to incident reporting systems (IRS) provide valuable information, but studies have shown errors frequently go unreported. In this study of medication errors in two children hospitals, out of 11,302 prescribing errors identified during audit, only 36 had been reported to the IRS; none of the 2,883 administration errors were reported to the IRS.
Haimi M, Wheeler SQ. JMIR Hum Factors. 2024;11:e50676.
Teletriage is a component of telehealth wherein patients or their families seek advice on their symptoms and whether, and how urgently, they should seek additional care. This article includes a narrative review and interviews with one American nurse and 15 Israeli pediatric physicians who practice teletriage. Despite the differences between provider profession and health care system, the same essential elements of safe teletriage were identified: specialized clinical training, electronic algorithms and protocols, documentation, and clinical call center standards.
Brooks KC, Raffel KE, Chia D, et al. JAMA Intern Med. 2024;184:704-706.
Stigmatizing language in electronic health records (EHR) has been shown to negatively impact the quality of patient care and patient hesitancy to seek future care. This study identified that stigmatizing language (questioning of patient credibility, racial or social class stereotyping, expressions of disapproval toward patients, and descriptions of difficult patients) was more common among Black patients than Asian or white, and more common among patients with housing instability. Further work is needed to explore and mitigate these associations.
Müller BS, Lüttel D, Schütze D, et al. J Patient Saf. 2024;Epub Mar 18.
Patient safety in ambulatory care settings is receiving increasing attention. This study evaluated an error management and safety climate intervention implemented across 184 ambulatory practices in Germany. The intervention included email newsletters on error management, e-learning modules to improve team engagement, and interdisciplinary workshops to discuss critical incidents. Survey feedback identified significant improvements in safety climate as well as improvements to incident reporting and learning systems.
Torzone A, Birely A. Curr Opin Cardiol. 2024;39:356-363.
High reliability organizations can operate in complex, high-risk situations for extended periods without sacrificing safety. This article discusses how high reliability concepts can be applied at pediatric cardiac centers to support safe, high-quality care. The authors highlight the importance of interprofessional collaboration, the role of nurses and advanced practice providers, and fostering psychological safety through hierarchy changes.
Ranasinghe S, Nadeshkumar A, Senadheera S, et al. BMJ Open Qual. 2024;13:e002570.
Preventable adverse events can lead to significant excess costs for patients, caregivers, and healthcare systems. This systematic review of 33 studies identified considerable variability in how the costs associated with medication errors are calculated and highlight the need for a validated, standard method for calculating these costs.
Kiljunen O, Savela R‐M, Välimäki T, et al. Res Nurs Health. 2024;Epub Mar 24.
Concerns about resident safety in nursing homes and residential care settings are not new but, but the COVID-19 pandemic brought these concerns to the fore. This review summarizes the managerial perspective of barriers and facilitators to resident safety in long-term care settings. Physical and human resources, and national regulations and networks emerged as pivotal factors in promoting resident safety. The results demonstrate the importance of organizational, not solely individual, support of resident safety work.
Haimi M, Wheeler SQ. JMIR Hum Factors. 2024;11:e50676.
Teletriage is a component of telehealth wherein patients or their families seek advice on their symptoms and whether, and how urgently, they should seek additional care. This article includes a narrative review and interviews with one American nurse and 15 Israeli pediatric physicians who practice teletriage. Despite the differences between provider profession and health care system, the same essential elements of safe teletriage were identified: specialized clinical training, electronic algorithms and protocols, documentation, and clinical call center standards.

Agency for Healthcare Research and Quality. May 23, 2024.

An understanding of organizational safety culture is fundamental to driving improvement. This webinar highlighted how the Indiana Hospital Association (IHA) used AHRQ’s Surveys on Patient Safety Culture® (SOPS®) Hospital Survey and Workplace Safety Supplemental Item Set to examine patient safety culture and workplace safety in 41 Indiana hospitals. Presenters discussed the survey results, how SOPS resources were used, and their focus on initiatives to address workplace safety, including burnout.

ISMP Medication Safety Alert! Acute Care. 2024;29(8):1-4.

A multitude of latent and active failures typically contribute to harmful medication errors in hospitals. This article examines a prolonged intravenous medication administration error and describes “holes in the Swiss cheese” that enabled the failure. Recommendations for improvement discussed in this article include daily review of medications, look-alike medication management, and infusion line verification.

Geneva, Switzerland: World Health Organization; April 2024. ISBN: 9789240093249.

Patients have the right to expect safe, equitable, high-quality care. This 10-point charter serves to describe the establishment of a broad-based global action plan that enables foundational work to be done in support of patient safety. The right to dignity, competent clinicians, and medical record access are amongst the required elements of the charter.

This Month’s WebM&Ms

WebM&M Cases
Sharmilee Vuyyuru, DO, and Nandakishor Kapa, MD |
A 57-year-old man was rushed to the Emergency Department from a nursing facility, struggling to breathe. With a history of hypertension, diabetes, and heart failure, his vital signs were concerning, showing high blood pressure, rapid heart rate, and low oxygen levels. Examinations revealed fluid buildup in his lungs and legs, indicating severe heart and kidney problems. Despite attempts to remove excess fluid with medication, dialysis became necessary. However, a complication arose during catheter insertion, requiring emergency surgery to retrieve a misplaced guidewire.
WebM&M Cases
Spotlight Case
Andrew P.J. Olson, MD, FACP, FAAP |
Five weeks after gastric bypass surgery, a woman experienced persistent nausea and vomiting, leading to dehydration and multiple outpatient treatments. Despite visiting an outpatient clinic and emergency department (ED) for ongoing symptoms and significant weight loss, the nausea and vomiting persisted. Eventually, she was admitted to the ICU with pancreatitis and dehydration. Subsequently, she exhibited neurological symptoms including difficulty walking, tingling sensations, and cognitive impairment. She was discharged with orders for total parenteral nutrition (TPN). Three days after discharge, she was readmitted for worsening confusion and profound motor weakness, which progressed to respiratory failure requiring mechanical ventilation. Laboratory tests revealed an extremely low thiamine level, and the patient was diagnosed with advanced Wernicke-Korsakoff Syndrome, exacerbated by a lack of proper nutrition, and resulting in permanent brain damage, necessitating ongoing care. The commentary discusses how biases associated with medical conditions, such as obesity and its treatment, can lead to poorer outcomes, as well as strategies to continually re-evaluate diagnostic reasoning in light of ongoing, intensive management and management reasoning
WebM&M Cases
Spotlight Case
Elizabeth Gould, NP-C, CORLN, Krystal Craddock, BSRC, RRT, RRT-ACCS, RRT-NPS, AE-C, CCM, Tyler Le Tellier, RRT, Brooks T Kuhn, MD, MAS |
A 55-year-old man with a history of osteoarthritis and supraventricular tachycardia was admitted the hospital with severe COVID-19 and required endotracheal intubation and invasive mechanical ventilation. Following transfer to a long-term care hospital (LTCH) for continued weaning from mechanical ventilation, inadequate tracheostomy management protocols were evident, with no specific instructions provided. Subsequently, the patient experienced respiratory distress and cardiac arrest due to a blocked tracheostomy tube, highlighting critical deficiencies in care and communication. The commentary summarizes the risk factors for tracheostomy complications, the importance of tracheostomy tube maintenance and monitoring, and strategies to safeguard tracheostomy tube care during transitions of care. 

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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