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June 26, 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

Bucknall TK, Guinane J, McCormack B, et al. J Clin Nurs. 2024;Epub May 31.
Rapid response teams (RRTs) or medical emergency teams (METs) are activated before clinical deterioration, or as soon as deterioration is recognized. In some hospitals, patients and families can activate an MET, and understanding their perspectives is important. For this study, patient and family perspectives of MET activation were sought prior to implementation of patient and family activated escalation system (PFAES) in two Australian hospitals. The overarching theme was help seeking, with four subthemes: identifying deterioration, voicing concerns, being heard, and trust and expectation.
Sullivan JL, Shin MH, Chan J, et al. Health Serv Res. 2024;Epub May 8.
Effective implementation of patient safety practices remains an organizational challenge. This qualitative study explored lessons learned and opportunities for improvement based on nationwide implementation of the VA Patient Safety Events in Community Care: Reporting, Investigation, and Improvement Guidebook aimed at standardizing patient safety practices in the Veterans’ Affairs (VA) Community Care Network. Researchers conducted semi-structured interviews with patient safety officers, quality managers, and community care staff, and identified barriers and facilitators to Guidebook implementation (e.g., resource availability, organizational culture). Qualitative findings underscored the importance of leadership engagement, role clarity, and effective communication.
Chandra K, Garcia M, Bajaj K, et al. Jt Comm J Qual Patient Saf. 2024;50:606-611 .
Root cause analysis (RCA) investigations are conducted to identify systemic issues that contributed to an adverse event. This study describes the development and implementation of a health equity tool embedded within one hospital’s RCA process. The tool assists in identifying equity-related internal (e.g., race, age), external (e.g., health literacy), and organizational (e.g., access) factors that could have impacted the outcome of the adverse event.
Lin L. BMJ Qual Saf. 2024;Epub Jun 11.
Accurate measurement of patient safety events remains challenging. Based on longitudinal claims data about global disease burden from 204 countries, this analysis found that the incidence of adverse events rose faster than global population growth between 1990 and 2019 (59.3% increase versus 44.6% increase), particularly among older adults. The authors note the importance of adverse event reporting and surveillance, particularly in countries with lower socioeconomic development.
Bucknall TK, Guinane J, McCormack B, et al. J Clin Nurs. 2024;Epub May 31.
Rapid response teams (RRTs) or medical emergency teams (METs) are activated before clinical deterioration, or as soon as deterioration is recognized. In some hospitals, patients and families can activate an MET, and understanding their perspectives is important. For this study, patient and family perspectives of MET activation were sought prior to implementation of patient and family activated escalation system (PFAES) in two Australian hospitals. The overarching theme was help seeking, with four subthemes: identifying deterioration, voicing concerns, being heard, and trust and expectation.
Cuaron JJ, McBride S, Chino F, et al. JAMA Netw Open. 2024;7:e2416570.
At the outset of the COVID-19 pandemic, many health systems transitioned to mandatory telehealth visits and then slowly reintroduced in-person visits as safety improved. This study describes patient safety, patient satisfaction, and financial savings for patients receiving radiation therapy who attended weekly management visits with their physician via telehealth instead of in-person. Safety event rates were similar for patients receiving telehealth and in-person care. Nearly all telehealth patients reported high satisfaction and cost savings.
Sullivan JL, Shin MH, Chan J, et al. Health Serv Res. 2024;Epub May 8.
Effective implementation of patient safety practices remains an organizational challenge. This qualitative study explored lessons learned and opportunities for improvement based on nationwide implementation of the VA Patient Safety Events in Community Care: Reporting, Investigation, and Improvement Guidebook aimed at standardizing patient safety practices in the Veterans’ Affairs (VA) Community Care Network. Researchers conducted semi-structured interviews with patient safety officers, quality managers, and community care staff, and identified barriers and facilitators to Guidebook implementation (e.g., resource availability, organizational culture). Qualitative findings underscored the importance of leadership engagement, role clarity, and effective communication.
Marsall M, Hornung T, Bäuerle A, et al. BMC Health Serv Res. 2024;24:576.
Transitions of care from inpatient to home settings can introduce opportunities for errors and adverse events. In this survey of 825 patients discharged home after an inpatient care stay, participants reported that higher quality care transitions were associated with fewer self-reported medication-related complications and better health status, but not with readmissions.
Eskreis-Winkler L, Woolley K, Erensoy E, et al. J Exp Psychol Gen. 2024;Epub Jun 10.
Failure can be considered a learning opportunity under the right conditions and the right organizational culture. This article describes seven studies concerning people’s estimates of learning from previous failures (e.g., percent of nurses who pass the licensing exam after previously failing it) in various settings. Respondents consistently overestimated the success rate following failure in each of the study scenarios.
Zawati M'n H, Lang M. J Med Internet Res. 2024;26:e50344.
Patient use of artificial intelligence (AI)-based symptom checkers is increasing, but concerns remain regarding tool validation and appropriate use. This article discusses AI-powered symptom check apps and how implicit and explicit biases (e.g., health literacy, the racial and/or gender breakdown of the underlying data), as well as perceptions about integration in professional practice, can influence effective implementation of these tools.
Joseph S, Selvaraj J, Mani I, et al. Am J Ophthalmol. 2024;263:214-230.
Artificial intelligence (AI) has been shown to have similar diagnostic accuracy to humans in mammography and other imaging studies. This review summarizes the accuracy of AI-based diabetic retinopathy (DR) screening from retinal images. Pooled analysis from 34 studies shows AI-based screening has acceptable performance for DR screening.
Corvaisier M, Brangier A, Annweiler C, et al. J Nutr Health Aging. 2024;28:100187.
Older adults who take potentially inappropriate medications (PIM) are at increased risk of adverse events such as falls. This review focuses specifically on potentially inappropriate psychotropic (PIP) use in older adults. These studies investigated the association with PIP use association of falls, mortality, negative impact on ability to participate in activities of daily living, and unplanned hospitalizations; the use of a PIP increased the risk of all four outcomes.
Sexton JR, Kelly-Weeder S. J Patient Saf. 2024;Epub May 16.
Full disclosure after a preventable patient safety event is encouraged in healthcare, but much of the research focuses on disclosure behavior among physicians. This scoping review identified a significant gap in the literature examining the role of pediatric nurses during a patient safety event disclosure.

Agency for Healthcare Research and Quality. July 24, 2024 | 2:30– 4:00 PM (eastern).

Medication errors are a leading cause of injury and avoidable harm in health care that generates substantial economic burden worldwide. This session will provide insight on how quality improvement approaches and digital healthcare interventions such as clinical decision support tools are reducing medication errors, improving provider effectiveness, and enhancing patient safety in a variety of clinical care settings.

Kamb L. NBC News. June 14, 2024,

Transparency is a primary element of an organizational safety culture that enables recognition of medical error to inform improvement and responsible redress for the patient and family. This news story discusses the use of nondisclosure agreements, commonly known as NDAs, as tools that enable hospitals and clinicians to avoid legal resolution of poor care incidents.

Liverpool L. New York, NY: Astra Publishing House; 2024. ISBN‏: ‎9781662601675.

People of color are routinely affected by biased decision making in health care. This book examines the phenomenon of discrimination as it impacts health worldwide. The author distills evidence and stories to support arguments in favor of the need for national policy to dislodge racism as the public health and safety threat it is.

This Month’s WebM&Ms

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. 
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
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