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July 10, 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

Burden M, Astik GJ, Auerbach AD, et al. JAMA Intern Med. 2024;184(9):1014-1023.
Administrative harm (AH) may emerge from organizational decisions based on financial, regulatory, and other non-critical factors and can adversely impact patients and staff. In this study, hospitalists, leaders, researchers, and patient and family advocates were largely unaware of the term administrative harm but were familiar with these types of decisions. Three themes emerged: AH is pervasive and comes from all levels of leadership; organizations lack mechanisms to study AH; and organizational pressures are contributing factors.
Chitavi SO, Patrianakos J, Williams SC, et al. Jt Comm J Qual Patient Saf. 2024;50(6):393-403.
Preventing suicide among patients who express suicidal ideation or are identified at risk of suicide during care is a Joint Commission National Patient Safety Goal. This study surveyed Joint Commission-accredited hospitals regarding their implementation of four recommended discharge practices for suicide prevention: formal safety planning, lethal-means safety planning, warm handoffs to outpatient care, and follow-up with patients after discharge. Most of the responding hospitals had implemented some of the recommended suicide prevention strategies, and 4% had implemented all four components.
Glarcher M, Rihari-Thomas J, Duffield C, et al. Contemp Nurse. 2024;Epub Jun 11.
Each member of the care team brings a unique perspective towards patient safety. In this study, advanced practice nurses (APN) working in hospitals or community care described their experiences of patient safety improvement. Six themes were identified, including seeing patient safety as their top priority and being a role model to other staff.
Harvey B, Dhalla IA, O'Neill C, et al. Healthc Q. 2024;27(1):19-25.
Error reporting and analysis is a key element of a learning organization. This article describes one healthcare organization's approach to systematic review of serious harm events through use of a standardized classification system, frequent meetings, inclusion of the patient and family voice, and application of human factors strategies.
Hughes K, Cole M, Tims D, et al. Hosp Pediatr. 2024;14(6):448-454.
Smart pumps with dose error reduction software (DERS) can reduce adverse drug events, but alert fatigue can result in staff resistance and unsafe workarounds. In this study, a pediatric hospital aimed to increase use of smart pumps with DERS from 46% compliance at baseline to 75%. Updating the drug library resulted in the largest increase in compliance and decrease in alerts.
Creese J, Byrne JP, Conway E, et al. Health Serv Manage Res. 2024;Epub May 31.
Frontline staff are routinely encouraged to report patient safety problems, but many feel discouraged by management's response, or lack thereof, and thus they stop reporting. In this study, physicians reported three major barriers to speaking up: organizational deafness, disconnect between frontline staff and managers, and management denial of issues raised. As a result, physicians experienced burnout, moral injury, and job dissatisfaction. Fostering clear feedback pathways, genuine connection between physicians and managers, and an organizational commitment to accountability may increase physician willingness to speak up about patient safety concerns.
Fu S, Wang L, He H, et al. J Am Med Inform Assoc. 2024;31(7):1493-1502.
Standardized taxonomies allow for consistency across settings and enhance research and analysis. This article describes the collaborative effort of developing a standardized taxonomy based on errors from two natural language processing (NLP) models. There was high variability in error types across approaches and electronic health record systems; continued research and refinement is still needed.
Glarcher M, Rihari-Thomas J, Duffield C, et al. Contemp Nurse. 2024;Epub Jun 11.
Each member of the care team brings a unique perspective towards patient safety. In this study, advanced practice nurses (APN) working in hospitals or community care described their experiences of patient safety improvement. Six themes were identified, including seeing patient safety as their top priority and being a role model to other staff.
Denecke K, Paula H. Stud Health Technol Inform. 2024;313:1-6.
Natural language processing (NLP) has been used to categorize patient safety reports and reduce the burden of manual review within hospitals or hospital networks. This study uses NLP to analyze more than 10,000 reports submitted to the Swiss National CIRRNET database from 2006 to 2023. Most incidents were medication-related, followed by patient falls, and incidents related to venous thromboembolism.
Clausen MK, Bogh SB, Schmidt-Petersen M, et al. BMJ Open Qual. 2024;13(2):e002745.
Patient complaints can highlight previously unidentified areas of concern. This study analyzed patient complaints related to nutrition issues experienced during their hospital stay. Of the 89 nutrition-related problems, 20% were very severe, including one that resulted in patient death. While the article does not report the overlap between patient- and staff-reported nutrition incidents, the patient complaints shine a light on areas for deeper investigation.
Peterson KS, Chapman AB, Widanagamaachchi W, et al. PLOS Digit Health. 2024;3(6):e0000528.
Developing machine learning (ML) models to detect real time adverse events requires careful validation of proposed approaches. This article describes two ML models to detect diagnostic divergence (i.e., the deviation between predicted diagnosis and documented diagnosis, weighted by mortality) of pneumonia in the emergency department (ED). More than 6.5 million ED visits were analyzed by the models and 130 were analyzed by expert physicians for diagnostic divergence. Correlation between human and automatic reviewers was weak to moderate. The authors present potential reasons for this outcome and propose future research to improve ML accuracy.
Harvey B, Dhalla IA, O'Neill C, et al. Healthc Q. 2024;27(1):19-25.
Error reporting and analysis is a key element of a learning organization. This article describes one healthcare organization's approach to systematic review of serious harm events through use of a standardized classification system, frequent meetings, inclusion of the patient and family voice, and application of human factors strategies.
Eriksson M, Blomberg K, Arvidsson E, et al. BMC Health Serv Res. 2024;24(1):737.
Primary care, like all healthcare, is increasingly shifting to team-based care with nurse practitioners, physician assistants, physicians, pharmacists, and other providers all collaborating to provide care to patients. This study looks at variation between general practitioner-only (GP) and multi-professional practices regarding quality and safety changes during the COVID-19 pandemic in Europe. Multi-professional practices were more likely to have made structural changes than GP-only, which the authors suggest may be due, in part, to larger multi-professional practices having more resources available than GP-only, which tend to be smaller.
Chitavi SO, Patrianakos J, Williams SC, et al. Jt Comm J Qual Patient Saf. 2024;50(6):393-403.
Preventing suicide among patients who express suicidal ideation or are identified at risk of suicide during care is a Joint Commission National Patient Safety Goal. This study surveyed Joint Commission-accredited hospitals regarding their implementation of four recommended discharge practices for suicide prevention: formal safety planning, lethal-means safety planning, warm handoffs to outpatient care, and follow-up with patients after discharge. Most of the responding hospitals had implemented some of the recommended suicide prevention strategies, and 4% had implemented all four components.
Cuba L, Dürr P, Dörje F, et al. Clin Pharmacol Ther. 2024;116(1):194-203.
Randomized controlled trials (RCT) are conducted with stringent inclusion criteria and thus may not reflect real-world clinical practice. This study compares the medication error rates of the AMBORA care program implemented in routine clinical care with the rates found during the RCT. Medication errors were significantly more common in the real-world setting, potentially due to more complex oral antitumor therapy combination regimens or higher number of total medications per patient. Other demographics and outcomes (e.g., type of error) were similar in both groups.
Burden M, Astik GJ, Auerbach AD, et al. JAMA Intern Med. 2024;184(9):1014-1023.
Administrative harm (AH) may emerge from organizational decisions based on financial, regulatory, and other non-critical factors and can adversely impact patients and staff. In this study, hospitalists, leaders, researchers, and patient and family advocates were largely unaware of the term administrative harm but were familiar with these types of decisions. Three themes emerged: AH is pervasive and comes from all levels of leadership; organizations lack mechanisms to study AH; and organizational pressures are contributing factors.
Kato D, Lucas J, Sittig DF. J Am Med Inform Assoc. 2024;31(7):1588-1595.
Standardized classification of patient safety issues enables aggregation of problems to create system-wide solutions. In this study, twelve months of health information technology (HIT) incidents were retrospectively reviewed and classified into one of five types: HIT failures, unmet user needs, external system interactions, absence of HIT features, and not enough information to assess. After the retrospective phase, classification of reports was integrated into weekly meetings. Prospective categorization was efficient and allowed for more real-time analysis of HIT safety concerns.
Schmaltz SP, Longo BA, Williams SC. Jt Comm J Qual Patient Saf. 2024;50(6):425-434.
Organizations such as the Joint Commission provide resources and guidance to help hospitals reduce healthcare associated infections (HAIs). Using CMS data from 2017 to 2021, this analysis compared the incidence of HAIs in Joint Commission-accredited versus non-accredited long-term care hospitals (LTCHs). The researchers found that accredited LTCHs had lower rates of central line-associated blood stream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) compared to non-accredited hospitals; no differences were observed for Clostridium difficile infections (CDI).
Hughes K, Cole M, Tims D, et al. Hosp Pediatr. 2024;14(6):448-454.
Smart pumps with dose error reduction software (DERS) can reduce adverse drug events, but alert fatigue can result in staff resistance and unsafe workarounds. In this study, a pediatric hospital aimed to increase use of smart pumps with DERS from 46% compliance at baseline to 75%. Updating the drug library resulted in the largest increase in compliance and decrease in alerts.
Hasimja-Saraqini D, McNeill K, Kuk H, et al. Acad Med. 2024;99(7):736-740.
Getting full participation from physicians has historically been a challenge to implementing quality and patient safety improvement projects. This article describes an academic medical center's efforts to increase physician participation by improving organizational culture and establishing infrastructure to support participation. Two patient safety initiatives were positively impacted by increasing physician participation: length of stay in the emergency department and reducing unnecessary urinary catheter use.
Sutton E, Ibrahim M, Plath W, et al. BMJ Qual Saf. 2024;Epub Jun 20.
Patients and caregivers plan an important role in identifying early signs of clinical deterioration. This qualitative study examines the implementation of the Rescue for Emergency Surgery Patients Observed to uNdergo acute Deterioration (RESPOND) program, a patient-led escalation system in emergency surgical care in the United Kingdom. Participants identified important enablers of successful implementation, such as leadership support, as well as barriers, such as resistance to changing professional practice and disrupting norms.
Woodier N, Burnett C, Sampson P, et al. J Patient Saf Risk Manag. 2024;29(4):195-201.
Near misses and close calls are patient safety events that have the potential to cause patient harm but ultimately did not. This mixed method study with healthcare professionals, regulatory bodies, and representatives of other high reliability industries explored the key features of near miss identification, reporting, and learning. Participants identified several situations constituting near misses in different industries but note a lack of clear agreement on the features and definition of a near miss. 
Shennan S, Coyle N, Lockwood B, et al. J Patient Saf. 2024;20(6):434-439.
Isolation precautions, such as those to prevent the spread of COVID-19 or other healthcare-associated infections, can result in unintended consequences for patient safety. In this study, researchers examined the relationship between visitor restrictions during the COVID-19 pandemic and falls with harm at one Canadian hospital. Findings indicate that only the most severe restrictions (no visitors permitted) were associated with an increase in falls with harms.
Fleisher LA, Economou-Zavlanos NJ. JAMA Health Forum. 2024;5(6):e241369.
Artificial intelligence (AI) is being characterized as a medical device that requires guidance to ensure its safe use in health care. The authors highlight existing authority through the Centers for Medicare & Medicaid Services (CMS) and other government entities to track and respond to instances of AI use that result in patient harm. They also call for specific training developments that enable clinicians to apply AI-generated information effectively in front-line care.
Handley GM. BMJ. 2024;385:q1318.
Communication and resolution programs (CRPs) are an important strategy supporting full disclosure and psychological healing after a medical adverse incident, and they are not yet widely integrated into health care. This commentary describes one patient’s experience with a medical error and the lack of opportunity to work with the hospital’s CRP. The commentary authors also discuss the characteristics of CRPs and information about their existence that minimize patient and family access to them.
Hsu E, Ma S, Winn B, et al. NEJM Catalyst. 2024;5(7):CAT.24.0049.
Despite widespread adoption of value-based care (VBC), also known as pay-for-performance, its impact on patient safety is inconsistent. This article outlines one VBC program which includes more than 700 hospitals. In contrast to some other programs, the VBC program bases the overall score on nationally-normalized safety measures and does not penalize lower-performing hospitals. Lower-performing hospitals receive extra financial support and are rewarded for year-over-year improvement.
Pronovost PJ, Carrington EM. BMJ Qual Saf. 2024;33(11):755-758.
Patients managing chronic health conditions can be vulnerable to patient safety events during hospitalizations. Using Parkinson’s disease as an example, the authors present a framework for systematically identifying and mitigating patient safety risks in hospitalized patients with chronic health conditions. The framework underscores the importance of identifying high-risk patients and implementing appropriate interventions as close to admission as possible and the role of health information technology, such as electronic health records, to achieve this goal.
Salinas MP, Sepúlveda J, Hidalgo L, et al. NPJ Digit Med. 2024;7(1):125.
Artificial intelligence (AI)-based clinical decision support tools are increasingly used in dermatology. This systematic review and meta-analysis of 19 studies found that AI algorithms for skin cancer classification performed better than general clinicians and non-expert dermatologists, and were comparable to expert dermatologists.
Kissler MJ, Porter S, Knees M, et al. Ann Intern Med. 2024;177(7):941-952.
Factors detrimental to clinician attention, such as distractions or alarm fatigue, can threaten patient safety. This scoping review of 585 articles identified 82 metrics used to measure clinician attention and identified several key concepts influencing how attention is measured, including the clinical environment, the impact of alarm fatigue, and the role of health information technology.
Carollo M, Crisafulli S, Vitturi G, et al. J Am Geriatr Soc. 2024;72(10):3219-3238.
Potentially inappropriate medications (PIM) and polypharmacy in older adults contribute to increased risk of hospitalization. This systematic review and meta-analysis evaluated the impact of medication review and deprescribing interventions on hospitalized older adults' clinical outcomes including mortality and hospitalizations. Medication review and deprescribing resulted in a slight reduction of rehospitalizations with no impact on mortality.
Yan L, Karamchandani K, Gaiser RR, et al. Anesth Analg. 2024;139(1):68-77.
Unconscious bias among clinicians can hinder the delivery of high-quality care and degrade diagnostic decision making. This article summarizes unconscious cognitive biases in healthcare, emphasizing those biases particularly relevant to perioperative care such as confirmation bias and availability bias. The authors also review strategies to improve unconscious cognitive biases, including cognitive debiasing and clinical decision support systems (CDSS).

Agency for Healthcare Research and Quality. July 25, 2024.

Teamwork in the surgical suite is core to safe care but can be challenging to achieve. This webcast provided background on AHRQ’s Surveys on Patient Safety Culture® (SOPS®) Program, the & TeamSTEPPS® 3.0 team training curriculum, and how the use of TeamSTEPPS improves SOPS scores. The session highlighted how these efforts improved patient safety culture and team communication in a hospital surgery department.

Deng F. AJR Am J Roentgenol. July-September 2024.

Reducing diagnostic errors relies on a variety of professionals across the spectrum of care. This podcast series examines diagnosis and the role of radiologists and pathologists in the process. Episode 4 discusses methods for mitigating diagnostic error in radiology. The issue examines these points through the lens of human factors. 

Pradhan R, Wells K. KFF Health News and Morning Edition, Michigan Public Radio: June 19, 2024.

Cybersecurity is increasingly seen as a strategy supporting patient safety. This feature shares a nurse’s experience, at a large health system, in managing the effect a ransomware incident had on patient care delivery. The story highlights the impact of the system shutdowns on access to patient records, communication systems, and safety mechanisms.

Am J Health Syst Pharm. 2024;81(supp 3):s73-s136.

Parenteral nutrition (PN) is comprised of complex processes and prone to errors that can degrade therapy effectiveness and safety. This supplement highlights presentations from the 2021 International Safety and Quality of Parenteral Nutrition (PN) Summit and the resulting best practice consensus of the participants. The content examines international perspectives supporting safe parenteral nutrition strategies supporting adult patients in a variety of settings.

Massey W, Keith C. Spotlight PA: June 20, 2024.

Whistleblowers require a safety culture to provide the psychological and career protection that enables them to raise systemic safety concerns. This story shares the challenges and disruption a transplant surgeon encountered while trying to discuss contributors to troubling patterns at his institution that resulted in poor patient access to organs as well as post-surgical complications.

This Month’s WebM&Ms

WebM&M Cases
Spotlight Case
Scott Zakaluzny, MD, FACS |
A 67-year-old man with severe low back pain was admitted to the hospital for anterior lumbar interbody fusion (ALIF) with bone autograft from the iliac crest. The surgical team had difficulty controlling bleeding and the patient left the operating room (OR) with the bone graft donor site open and oozing blood. In the postanesthesia care unit (PACU), the nurse called the attending physician three times to report hypotension and ongoing bleeding. Each time, the surgeon ordered hetastarch for volume expansion. Over the next 14 hours, the patient’s blood pressure remained at or below 90/60 with continued complaints of back and pelvic pain. The next morning, the patient was unresponsive and in severe hypovolemic shock. Electrocardiography confirmed a non-ST segment elevation myocardial infarction (NSTEMI). The patient was transferred to an intensive care unit and resuscitative efforts were initiated, but the patient expired from multiorgan failure resulting from hypovolemic shock. The commentary discusses appropriate management of ongoing intraoperative and postoperative bleeding and how a culture of safety can enable care team members to voice concerns about patient safety. 
WebM&M Cases
Christian Bohringer, MB BS and Gustavo Chavez, MD |
A 36-year-old woman with class 2 obesity underwent a difficult laparoscopic hysterectomy, performed in the lithotomy position with a steep head down (Trendelenburg) position. Intermittent pneumatic compression devices were placed on both calves to prevent venous thrombosis (DVT), but on awakening from general anesthesia, the patient complained of severe pain in the right leg. The gynecologist made a presumptive diagnosis of DVT and put her on subcutaneous dalteparin at therapeutic dosing and acetaminophen and oral morphine for pain relief. The patient continued to complain of severe pain and paresthesias in her right calf and doppler ultrasound scan was negative for DVT. The next day the orthopedic on-call team was consulted and diagnosed compartment syndrome of the right leg. The patient required fasciectomy of the right leg and excision of necrotic muscle tissue, with a prolonged hospital stay. The commentary discusses how patient positioning during surgery can increase the risk for surgical complications, the role of interdisciplinary teamwork to achieve optimal positioning, and the importance of early identification of compartment syndrome to prevent permanent injury. 
WebM&M Cases
Paul MacDowell, PharmD, BCPS and Eloh McGee, PharmD |
A 19-month-old boy was being transferred to a tertiary medical center from another emergency department after undergoing comprehensive resuscitation efforts due to cardiopulmonary arrest. The transport clinician intended to administer rocuronium (a neuromuscular blocking agent) to treat ventilator desynchrony, but instead unintentionally administered flumazenil (a benzodiazepine antagonist). The clinician promptly corrected the error by administering the appropriate dose of rocuronium. The commentary highlights the importance of “double checks” during medication administration and how both technologic approaches and human factors engineering principles can support safe medication administration practices.

This Month’s Perspectives

Amy Helwig headshot
Interview
Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD |
Amy Helwig, MD, MS, FAAFP, is the Chief Quality Officer at Commonwealth Care Alliance. We spoke to her about the health plan’s role in monitoring and improving patient safety. 
Perspectives on Safety
Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD |
This piece explores the health plan’s role in improving patient safety, including how health plans are monitoring patient safety and health plan-level initiatives to improve patient safety. 
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