Sorry, you need to enable JavaScript to visit this website.
Skip to main content

May 15, 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

Levine DM, Syrowatka A, Salmasian H, et al. Ann Intern Med. 2024;177:738-748.
Although most care occurs in outpatient settings, research into adverse events (AE) in this setting remains sparse in comparison to acute care. In this study, the medical records of patients who received outpatient care (e.g., primary, radiology, emergency, ambulatory surgery) in Massachusetts in 2018, were reviewed for any occurrence of adverse events. Seven percent had at least one AE, most commonly adverse drug events, and 23% were potentially preventable. Most AE originated from care in the physician's office.
Magerøy M, Braut GS, Macrae C, et al. J Healthc Leadersh. 2024;16:193-208.
Nursing homes face serious, ongoing patient safety challenges. This qualitative data analysis identified challenges and facilitators that are experienced by nursing home leaders in Norway as they manage the dual responsibilities of Health, Safety and Environment (HSE) and Quality and Patient Safety (QPS). The analysis identified four themes – temporal capacity, relational capacity, professional competence, and organizational structure – highlighting the importance of adequate resources, teamwork, and strong organizational safety culture.
Osei-Poku GK, Prentice JC, Easter SR, et al. Am J Obstet Gynecol. 2024;Epub Mar 2.
Obstetric care is a complex, high-risk heath care environment. This analysis of 64,441 deliveries in Massachusetts in 2019 found that individuals delivering in hospitals with risk-inappropriate resources were more likely to experience severe maternal morbidity. Among the one-third of individuals with a high-risk obstetric condition, 13% delivered at a hospital with inadequate resources for their condition. The authors conclude that hospitals can use a Levels of Care Assessment Tool to better understand their resources and capabilities to ensure that everyone receives risk-appropriate care.
Osei-Poku GK, Prentice JC, Easter SR, et al. Am J Obstet Gynecol. 2024;Epub Mar 2.
Obstetric care is a complex, high-risk heath care environment. This analysis of 64,441 deliveries in Massachusetts in 2019 found that individuals delivering in hospitals with risk-inappropriate resources were more likely to experience severe maternal morbidity. Among the one-third of individuals with a high-risk obstetric condition, 13% delivered at a hospital with inadequate resources for their condition. The authors conclude that hospitals can use a Levels of Care Assessment Tool to better understand their resources and capabilities to ensure that everyone receives risk-appropriate care.
Magerøy M, Braut GS, Macrae C, et al. J Healthc Leadersh. 2024;16:193-208.
Nursing homes face serious, ongoing patient safety challenges. This qualitative data analysis identified challenges and facilitators that are experienced by nursing home leaders in Norway as they manage the dual responsibilities of Health, Safety and Environment (HSE) and Quality and Patient Safety (QPS). The analysis identified four themes – temporal capacity, relational capacity, professional competence, and organizational structure – highlighting the importance of adequate resources, teamwork, and strong organizational safety culture.
Manojlovich M, Bettencourt AP, Mangus CW, et al. Jt Comm J Qual Patient Saf. 2024;50:348-356.
Communication breakdowns can lead to diagnostic errors in the emergency department (ED). This qualitative study used the eDelphi methodology to refine an existing diagnostic decision-making framework for EDs, emphasizing the importance of communication throughout the diagnostic process. The revised framework identifies critical points where communication breakdowns are likely to occur during the provision of care in the ED and strategies to address these issues.
Bahadurzada H, Kerrissey M, Edmondson AC. Healthcare (Basel). 2024;12:812.
When staff feel psychologically safe, they are more likely to engage in safety behaviors such as reporting errors and asking questions. This study explored the association of psychological safety and joint-problem-solving orientation (JPS; e.g., addressing problems as a team effort) with safety improvement and intent to leave. When staff reported feeling psychologically safe, they reported lower intent to leave and higher levels of safety improvement; this association was stronger when they also reported high levels of JPS.
O’Malley R, O’Connor P, Lydon S. BMC Prim Care. 2024;25:141.
The delivery of high-quality, safe health care involves individual behaviors, organizational processes, and contextual factors. This analysis of qualitative data from patients, primary care providers, and practice administrators uses a Safety-II framework to explore several types of factors contributing to high-quality primary care, such as electronic referrals, effectively managing patient flow, and mitigating delayed wait times, and a supportive, respectful work environment.
Meredith LS, Ahluwalia SC, Chen PG, et al. JAMA Netw Open. 2024;7:e244192.
Many healthcare workers experienced burnout, fatigue, and other adverse psychological outcomes stemming from the COVID-19 pandemic. This study examined the impact of a peer-to-peer support intervention (Stress First Aid) to improve health care worker well-being during the COVID-19 pandemic. Among 28 hospitals and federally qualified health centers (FQHCs) and 2,077 health care workers, the intervention did not improve well-being outcomes, but it did have a protective effect against general psychological distress and post-traumatic stress disorder among health care workers in facilities with higher implementation adherence.
Levine DM, Syrowatka A, Salmasian H, et al. Ann Intern Med. 2024;177:738-748.
Although most care occurs in outpatient settings, research into adverse events (AE) in this setting remains sparse in comparison to acute care. In this study, the medical records of patients who received outpatient care (e.g., primary, radiology, emergency, ambulatory surgery) in Massachusetts in 2018, were reviewed for any occurrence of adverse events. Seven percent had at least one AE, most commonly adverse drug events, and 23% were potentially preventable. Most AE originated from care in the physician's office.
Rosario N, Kiles TM, M. Jewell T'B, et al. Res Social Adm Pharm. 2024;20:670-677.
Racism is a pervasive threat to patient safety. This article discusses the relationship between racial and ethnic harm (e.g., racism, health disparities) and patient safety through the lenses of social learning theory, critical race theory, and medical racism. The authors outline several strategies to reduce harm and improve patient safety among racially or ethnically marginalized patients, such as antiracism education and addressing harm promptly when it occurs.
Bredenkamp K, Raschka MJ, Holmes A. J Pediatr Pharmacol Ther. 2024;29:100-106.
Even with technology designed to prevent them, medication errors continue to occur, often causing staff involved to experience "second victim" syndrome. This article, with a focus on pediatric pharmacists, presents four programs designed to support second victims: MU Health’s forYOU, Johns Hopkins’ RISE, Nationwide Children’s YOU Matter, and Children’s Minnesota’s (Children’s MN’s) P2P (peer-to-peer) program. The authors also present options for support that individuals can access if their institution does not have a formal second victim program.
Grygorian A, Montano D, Shojaa M, et al. JAMA NetwOpen. 2024;7:e248555.
Although research into telehealth shows generally positive patient outcomes, it is important consider the types and mode of telehealth delivery and specific clinical contexts. This review summarizes findings from 19 studies on pre- and/or post-operative telehealth for patients undergoing abdominal surgery. The telehealth care was provided by phone or video, mobile application, or remote monitoring. Emergency department visits and hospital readmissions were lower in telehealth vs. conventional care, and there were no differences in post-operative complications. Continued research is needed to understand which components of telehealth show the most promise.
Gampetro PJ, Nickum A, Schultz CM. J Patient Saf. 2024;Epub Apr 30.
Incident reporting systems (IRS) allow providers, staff, and, in some cases, patients and families, to report healthcare errors or near misses. This systematic review contrasts barriers reported by providers and staff in the US and the UK. Providers in both countries cited fear of punitive response or retaliation, shame, and concerns about confidentiality as reasons for not submitting reports. UK providers more frequently identified concerns about damaging the professional culture within and between healthcare teams.
Hammoud S, Alsabek L, Rogers L, et al. BMC Health Serv Res. 2024;24:532.
Patient and public involvement (PPI) in patient safety research is encouraged by funding agencies and advocacy organizations. The goal of this review was to examine the frequency and quality of PPI reporting in patient safety research using the Guidance for Reporting Involvement of Patients and the Public (GRIPP2) checklist. Of the 82 included studies, only five reported using the GRIPP2 checklist and only three reported on all five aims of PPI (e.g., aim of PPI, the extent to which PPI influenced the study). Publishers, researchers, and funders are encouraged to require use of PPI and the GRIPP2 checklist to improve patient and public involvement.
No results.

Ratwani RM, Bates DW, Gold J. Health Affairs Forefront. April 25, 2024.

Design and user issues are persistent detractors from the reliability of electronic health records (EHRs) in the diagnostic process. This piece explores the lack of knowledge regarding the intersection of EHRs and diagnostic error. It suggests enhanced EHR design and training as avenues toward improvement.

Robertson R. MedPage Today. April 30, 2024.

Criminalization of medical error can have a chilling effect on the transparency needed to inform improvement. This news article highlights the first law in the United States to protect clinicians who make honest errors from facing criminal prosecution.

Graham J. KFF Health News. May 6, 2024.

The boarding of patients that present with emergent needs reduces safety and access to care for those patients and others. This article discusses overcrowding as it impacts older emergency room patients and the systemic issues that contribute to boarding.

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.
Stay Updated!
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. Sign up today to get weekly and monthly updates via emails!