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July 31, 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
Dukhanin V, Wiegand AA, Sheikh T, et al. Diagnosis (Berl). 2024;11(4):389-399.
Reducing health disparities and achieving diagnostic excellence requires a multidisciplinary approach. This article describes development of 21 potential solutions for diagnostic disparities and four expertise categories for implementation. Healthcare systems, educators, researchers, and health information technologists, in partnership with patients throughout the diagnostic process, were identified as having primary expertise in creating and adopting solutions.
Garratt S, Dowling A, Manias E. J Adv Nurs. 2024;Epub Jul 7.
Medication administration is a complex process with many opportunities for errors. This systematic review identified 128 studies focused on medication administration in long-term geriatric care (e.g., assisted living, nursing homes). Five overarching themes were identified, including staffing and resident rights. The researchers identified two areas of high concern requiring additional research: classifying omissions as administration errors and dose form modification.
Katz U, Cohen E, Shachar E, et al. NEJM AI. 2024;1(5):5.
Before large language models (LLM) can be integrated into clinical care, they must be shown to perform at least as well as physicians. This study compared two publicly available GPT models with official physician scores on the Israeli board residency examinations in five core medical disciplines: internal medicine, general surgery, pediatrics, psychiatry, and obstetrics and gynecology (OB/GYN). GPT-4 performance was comparable to that of physicians taking the exam, whereas GPT-3.5 did not reach passing levels on any of the five exams.
Doub TW, Hickson GB, Casey VF, et al. J Bone Joint Surg Am. 2024;106(14):1286-1292.
Research has shown associations between patient complaints and patient outcomes. This study evaluated the impact of an evidence-based intervention to reduce patient complaints in one orthopedic practice. The Patient Advocacy Reporting System (PARS) includes a peer messenger component for the small proportion of clinicians whose practices are associated with a disproportionate share of patient complaints. Of the 42 physicians and physician assistants who were identified by PARS as at-risk for patient complaints, 90% improved following peer-delivered feedback. In addition, malpractice claims against those clinicians decreased by 87%.
Vasudevan A, Plombon S, Piniella N, et al. J Am Med Inform Assoc. 2024;31(10):2304-2314.
Patients are at increased risk of adverse events (AE) in the period following hospital discharge. This quality and safety improvement project aimed to reduce post-discharge AE and patient-reported new or worsening symptoms (NWS). The intervention included a patient-facing checklist whose responses were integrated into an electronic health record dashboard. AE were not significantly different between the intervention and usual care groups. NWS were non-significantly higher in the checklist group, which the authors propose may be due to the activating effects of the intervention, prompting patients to be aware of and report symptoms.
Boyer L, Wu AW, Fernandes S, et al. Front Public Health. 2024;12:1423905.
Witnessing or being part of an adverse patient safety event can result in increased anxiety of recurrence. This study of more than 10,000 healthcare workers (HCW) in France found a quarter of them report feeling afraid of making an error that could jeopardize patient safety at least once per week ("high fear"). High fear of making an error was associated previously with burnout, depression, anxiety, and sleep disorders, which can themselves influence patient safety.
Katz U, Cohen E, Shachar E, et al. NEJM AI. 2024;1(5):5.
Before large language models (LLM) can be integrated into clinical care, they must be shown to perform at least as well as physicians. This study compared two publicly available GPT models with official physician scores on the Israeli board residency examinations in five core medical disciplines: internal medicine, general surgery, pediatrics, psychiatry, and obstetrics and gynecology (OB/GYN). GPT-4 performance was comparable to that of physicians taking the exam, whereas GPT-3.5 did not reach passing levels on any of the five exams.
Tuyishime H, Claure RE, Balakrishnan K, et al. Jt Comm J Qual Patient Saf. 2024;50(9):678-683.
Team huddles are an effective way for healthcare teams to share information, proactively identify safety concerns, and increase accountability. This children's hospital implemented daily safety huddles in the operating room at the beginning of each day to reduce perioperative serious safety events (SSE). Following implementation, the perioperative service had no SSE for more than 900 days without delaying first-case start times.
Vehvilainen E, Charles A, Sainsbury J, et al. J Patient Saf. 2024;20(5):e73-e77.
Traditional organizational hierarchies can prevent staff and patients from speaking up about safety concerns. In this study, patients and providers describe ways organizational leadership can support efforts to flatten professional hierarchies and encourage open communication. Enablers include collaborative leadership, education, support, feedback, and learning. Overlaying all themes is the importance of psychological safety where staff feel their concerns will be heard and considered openly.
Groves PS, Farag A, Perkhounkova Y, et al. J Clin Nurs. 2024;Epub Jul 15.
As patients with safety concerns frequently report the concerns to their nurse, nurses' responses must be consistent across patients and free from bias. In this vignette study, nurses were presented with hypothetical patient complaints with varying combinations of patient demographics (e.g., race), complaint type (e.g., communication), and patient communication approach (e.g., confrontational). Nurses were asked to rate the credibility of the complaint, their level of concern, and intention to report the complaint to their incident reporting system. Results varied by patient and nurse characteristics.
Sharma AE, Tran AS, Dy M, et al. BMJ Qual Saf. 2024;Epub Jul 11.
Adverse event (AE) investigations typically only include organizational or regulatory professionals. This study included English-, Spanish-, and Cantonese-speaking patients and caregivers who receive care in a California public health system. In interviews and focus groups, participants were presented with two exemplars of an ambulatory AE and asked to describe potential contributing factors and preventive measures. Themes identified include: (1) patients and teams have specific safety responsibilities; (2) proactive communication drives safe ambulatory care; (3) barriers related to limited resources contribute to ambulatory AEs. This study demonstrates that patients and caregivers can make important contributions to AE reviews.
Pagali SR, Ryu AJ, Fischer KM, et al. J Patient Saf. 2024;20(5):352-357.
Interhospital transfers are complicated and present numerous safety challenges. In this study, outcomes of patients admitted to one hospital via the emergency department (ED) and via a transfer center (from outpatient, another hospital, or another ED) were compared. In both matched and unmatched cohorts, patients admitted via the referral center had longer length of stay and higher mortality and readmission rates. In addition, the transfer cohort had a higher utilization of palliative care services.
Dukhanin V, Wiegand AA, Sheikh T, et al. Diagnosis (Berl). 2024;11(4):389-399.
Reducing health disparities and achieving diagnostic excellence requires a multidisciplinary approach. This article describes development of 21 potential solutions for diagnostic disparities and four expertise categories for implementation. Healthcare systems, educators, researchers, and health information technologists, in partnership with patients throughout the diagnostic process, were identified as having primary expertise in creating and adopting solutions.
Stolte AR, Siwy YM, Tanios SB, et al. Patient Safety. 2024;6(1):117504.
System-based strategies are considered the most effective in reducing adverse events. This study evaluates the proposed action plan of an academic medical center following a fatal medication administration event against the Institute of Safe Medication Practices’ (ISMP) hierarchy of effectiveness. Only two of the 25 strategies were considered highly effective, high leverage system-based strategies. The authors also recommend fostering a “just culture” that advocates for system accountability.
Garratt S, Dowling A, Manias E. J Adv Nurs. 2024;Epub Jul 7.
Medication administration is a complex process with many opportunities for errors. This systematic review identified 128 studies focused on medication administration in long-term geriatric care (e.g., assisted living, nursing homes). Five overarching themes were identified, including staffing and resident rights. The researchers identified two areas of high concern requiring additional research: classifying omissions as administration errors and dose form modification.
No results.
Deutsch ES, Bajaj K. Rockville, MD: Agency for Healthcare Research and Quality; July 2024. Publication No. 24-0055.
Simulation can be used to identify latent safety threats, test new environments, and uncover team communication problems. This issue brief discusses approaches for advancing patient safety through simulation and debriefing. The combination of these two elements provides an adaptable training strategy for learning without direct harm to patients and designing improvements for use across an organization.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Lewis, MD |
A 54-year-old man with a history of tobacco use presented to the emergency department (ED) with acute chest pain. He was initially stable upon arrival, though with signs of fluid overload and electrolyte abnormalities including hyponatremia and hyperkalemia. Despite treatment including heparin, amiodarone, and metoprolol for atrial fibrillation, and interventions for hyperkalemia, the patient deteriorated rapidly into cardiac arrest characterized by Torsades de pointes, which was mistaken for ventricular fibrillation. Despite resuscitative efforts, he did not achieve return of spontaneous circulation and autopsy revealed sudden cardiac arrest without myocardial infarction as the cause of death. The commentary highlights how the misinterpretation of a common laboratory complication can lead to incorrect treatment and patient harm.
WebM&M Cases
Commentary by Brittany Newton, PharmD and Roslyn Seitz, MPH, MSN |
An adolescent with type 1 diabetes presented to the emergency department (ED) with dizziness, fatigue, and a “high” reading on her home blood glucose monitor. She was diagnosed with diabetic ketoacidosis (DKA) likely due to insulin pump malfunction. Despite initial treatment, her condition did not improve as expected. Later, it was discovered that an incorrect weight was used to calculate her insulin drip rate, based on a guessed weight provided by the patient upon admission. Once her actual weight was used to adjust treatment, her DKA resolved rapidly within 12 hours. The commentary discusses how human factors engineering and electronic health record (EHR) functionalities can optimize weight measurement during patient encounters and the role of clinical pharmacists in the ED to improve medication safety.
WebM&M Cases
Commentary by Robert M. Szabo, MD, MPH, FAOA |
A woman underwent surgery for carpal tunnel syndrome without complications and was discharged with instructions to avoid soaking her hand in water (to reduce infection risk) and return for suture removal in 10 days. Despite reporting symptoms such as warmth, redness, and pain in her wrist shortly after surgery, her concerns were not adequately addressed by the surgeon's office. The patient returned for suture removal and visit notes stated that the wound was not infected or swollen. However, the patient continued to report pain, swelling, redness and oozing at the incision site after suture removal. Two weeks later, she presented to the emergency department (ED) and diagnosed with a severe infection, leading to multiple hospitalizations and permanent impairment of her right hand. The commentary discusses the importance of preoperative discussions about post-operative care, including sterile practices, and the use of protocol-based management strategies for medical office personnel to ensure that patient interactions and communication are appropriately documented and acted upon
This Month’s Perspectives
Perspectives on Safety
Chalapathy Venkatesan, MD, MS, CPPS, Kathy Helak, MSN, BSN, RN, FACHE, CPPS, Zoe Sousane, BS, Cindy Manaoat Van, MHSA, CPPS |
Dr. Chalapathy Venkatesan is the Chief Quality and Safety Officer, and Kathy Helak is the Assistant Vice President for Patient Safety at Inova Health System. We spoke to them about Safety-II principles and their application at Inova.
Perspective
Chalapathy Venkatesan, MD, MS, CPPS, Kathy Helak, MSN, BSN, RN, FACHE, CPPS, Zoe Sousane, BS, Cindy Manaoat Van, MHSA, CPPS |
This piece provides an overview of Safety-II principles and discusses ways healthcare systems are integrating Safety-II principles into safety programs and care delivery.
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