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September 11, 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
Craske ME, Hardeman W, Steel N, et al. BMJ Qual Saf. 2024;Epub Jul 16.
At several points during a hospital stay, a patient may receive a medication review with a pharmacist to reduce the risk of medication errors. This review characterizes themes and components of pharmacist-led medication reviews associated with positive patient outcomes. Patient involvement in goal setting was identified as a successful component that would benefit from additional research.
Hager P, Jungmann F, Holland R, et al. Nat Med. 2024;Epub Jul 4.
Researchers, clinicians, and other stakeholders are hopeful that integration of artificial intelligence and large language models (LLMs) can improve patient safety and reduce clinician burden. This study used 2,400 real patient cases to test several LLM's ability to correctly diagnose common abdominal complaints. Each LLM performed significantly worse than physicians, did not follow treatment or diagnostic guidelines, could not interpret laboratory results, and often failed to follow instructions.
Rizk E, Kaur N, Duong PY, et al. Am J Health Syst Pharm. 2024;Epub Jul 1.
Overprescribing of opioids for acute pain (such as post-surgical pain) can increase the risk for long-term opioid dependence. This study evaluated whether implementation of an EHR alert reduced opioid overprescribing, defined as opioid prescribing exceeding current recommendations. Among a cohort of patients discharged after surgical procedures commonly associated with overprescribing (laparoscopic cholecystectomy, unilateral open inguinal hernia repair, and laparoscopic appendectomy), researchers identified a significant decrease in opioid overprescribing after the EHR alert implementation (48% pre-implementation to 3% post-implementation). Researchers also observed a significant decrease in the average opioid supply at discharge.
Beauvais B, Dolezel D, Shanmugam R, et al. Healthcare (Basel). 2024;12(13):1314.
Healthcare-associated infections (HAI) can have detrimental results for patients and organizations. This study used HAI and financial data from nearly 1,500 acute care hospitals to assess the association between hospital financial performance and methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C. diff), catheter-associated urinary tract infections (CAUTI), and central line-associated bloodstream infections (CLABSI) infection rates. Each of the HAIs was positively associated with increased hospital costs, underscoring the importance of infection control policies to patient health and hospital financial health.
Newman C, Mulrine S, Brittain K, et al. J Patient Saf. 2024;20(7):478-489.
Advancing patient safety in long-term care settings remains a challenge. This analysis of 91 incident reports from care homes in England examined patient safety events that occurred during transitions from hospital to care home. Common incidents included pressure injuries, medication errors, and premature discharge.
Bienefeld N, Keller E, Grote G. J Med Internet Res. 2024;26:e50130.
Numerous studies have investigated capabilities and accuracy of artificial intelligence (AI) in areas such as diagnosis. This study investigated data scientists' and clinicians' assessments of whether AI could/should be used in certain tasks regardless of AI's current abilities. Both groups said four out of six specified tasks (documentation, analyzing medical data, prescribing, diagnostic decision-making) could be performed by a combination of AI and clinicians. They reported monitoring patient data should be done by AI, and interactions with patients should never be done by AI.
Rizk E, Kaur N, Duong PY, et al. Am J Health Syst Pharm. 2024;Epub Jul 1.
Overprescribing of opioids for acute pain (such as post-surgical pain) can increase the risk for long-term opioid dependence. This study evaluated whether implementation of an EHR alert reduced opioid overprescribing, defined as opioid prescribing exceeding current recommendations. Among a cohort of patients discharged after surgical procedures commonly associated with overprescribing (laparoscopic cholecystectomy, unilateral open inguinal hernia repair, and laparoscopic appendectomy), researchers identified a significant decrease in opioid overprescribing after the EHR alert implementation (48% pre-implementation to 3% post-implementation). Researchers also observed a significant decrease in the average opioid supply at discharge.
Benetti PJ, Kanse L, Fruhen LS, et al. Safety Sci. 2024;178:106618.
Storytelling is an effective way to engage workers in safety strategies. In this study, leaders and workers in safety-critical industries describe what effective storytelling looks and sounds like. Six story attributes (e.g., relatability, factuality) and three presentation styles (e.g., delivery style) were identified. Addressing each attribute in their safety storytelling, leaders may more effectively engage workers in maintaining and improving safety.
Wong CI, Ilowite M, Yan A, et al. Pediatr Blood Cancer. 2024;71(8):e31064.
Eliminating central line-associated blood stream infections (CLABSI) remains a patient safety priority. This quality improvement project sought to reduce ambulatory CLABSI rates by improving caregiver management of central lines at home. The intervention included caregiver education, standardized ambulatory nurse CL care practice, and cleaning supplies. The evaluation identified a 52% decrease in ambulatory CLABSI rates, or 117 prevented infections.
Lebas R, Calvet B, Schadler L, et al. Res Social Adm Pharm. 2024;20(7):597-604.
The prevalence of medication errors in mental health settings is not well-represented in research. This study used 8 years of medication records to identify when in the medication process the error occurred and was identified, the consequences, type of drug, and root causes. Nearly one-third of errors were wrong dose and occurred in the prescribing stage. The type of error varied widely across medication types (e.g., high-alert, psychotropic).
Pohlman KA, Funabashi M, O’Beirne M, et al. PLoS ONE. 2024;19(8):e0309069.
Voluntary adverse event reporting among chiropractors is an ongoing challenge. Among 2,136 patients with chiropractic or physiotherapist office visits between October 2015 and December 2017, 21% reported experiencing an adverse event 2 to 7 days post-treatment, with the most common events being discomfort/pain, stiffness, and numbness.
Hager P, Jungmann F, Holland R, et al. Nat Med. 2024;Epub Jul 4.
Researchers, clinicians, and other stakeholders are hopeful that integration of artificial intelligence and large language models (LLMs) can improve patient safety and reduce clinician burden. This study used 2,400 real patient cases to test several LLM's ability to correctly diagnose common abdominal complaints. Each LLM performed significantly worse than physicians, did not follow treatment or diagnostic guidelines, could not interpret laboratory results, and often failed to follow instructions.
Kumarapeli P, Haddad T, de Lusignan S. Stud Health Technol Inform. 2024;316:746-750.
Detailed free-text information is collected and recorded in the EHR during primary care consultations, but much of it isn't fully used. This review highlights current challenges with and potential solutions for using large language models (LLMs) to transform clinical notes into rich data sources. LLMs can process free-text information to improve patient care, identify potential issues, and enhance patient-provider communication. Significant LLM fine-tuning and training would be required to make this process more effective.
Craske ME, Hardeman W, Steel N, et al. BMJ Qual Saf. 2024;Epub Jul 16.
At several points during a hospital stay, a patient may receive a medication review with a pharmacist to reduce the risk of medication errors. This review characterizes themes and components of pharmacist-led medication reviews associated with positive patient outcomes. Patient involvement in goal setting was identified as a successful component that would benefit from additional research.
Chance EA, Florence D, Sardi Abdoul I. Int J Nurs Sci. 2024;11(3):387-398.
Checklists and error reporting systems are designed to improve patient safety. This narrative review highlights the patient safety impacts of each, the similar challenges faced during implementation, and benefits of their use.
No results.
Rockville, MD: Agency for Healthcare Research and Quality; 2024. AHRQ Publication No. 24-0017-1-EF
Medication safety refers to practices and measures implemented to reduce the potential for medication errors and adverse drug events in various healthcare settings. This summary describes 123 AHRQ-supported projects associated with medication safety efforts. The most common strategies tested in this work focused on information technology, error reporting and analysis, and quality improvement. This summary is part of a series describing AHRQ-funded patient safety research; other summaries focus on care coordination and patient and family engagement.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute Care. August 22, 2024;29(17):1-3.
Overconfidence in the accuracy of computerized tools can result in errors being missed or blindly followed. This newsletter article discusses potential problems associated with the implementation of voice recognition software and highlights simulation, error reporting, and team involvement as avenues to minimize failures in using this technology to support medication processes.
(Cox C, Hughes H, Nicholls J, eds.). Somerset, UK: Class Publishing; 2024. ISBN 9781801610834.
Patient safety improvement builds on a wide array of theories to achieve success. This book highlights activities that support the implementation of foundational concepts such as safety science, human factors, and Safety II to a range of care environments through incident review case-based strategy.
Special or Theme Issue
Modi PK, Singer EA, eds. Urol Oncol. 2024;42(10):295-320.
Complications and medical errors can result in psychological distress for patients, families, and clinicians. This collection of articles examines this phenomenon in surgical care. Articles included touch on educational, organizational, and personal strategies to reduce the emotional impact of complications on surgeons.
This Month’s WebM&Ms
WebM&M Cases
Christian Bohringer, MBBS, Adam Guemidjian, and Garth Utter, MD, MSc |
An 8-year-old boy undergoing a neck mass aspiration experienced a sudden drop in oxygen saturation and heart rate, requiring CPR and intubation, due to being administered nitrous oxide instead of oxygen following a maintenance error by an inadequately trained employee. The patient was transferred to the intensive care unit (ICU) on a ventilator but remained unresponsive and died. The commentary discusses several approaches to improving patient safety during anesthesia administration in the surgical suite, such as use of oxygen analyzers and considering hypoxic gas mixture as the cause for sudden deterioration.
WebM&M Cases
Spotlight Case
David K. Barnes, MD, FACEP and Garth Utter, MD, MSc, FACS |
A man presented at the emergency department (ED) after a motorcycle crash. He had superficial lacerations on his left elbow, where wood chips were noted on exam and x-ray but were not fully removed before discharge. He was discharged with antibiotic prescriptions, but returned three days later with worsening symptoms, including pain, swelling, and pus, leading to additional foreign material being removed and further antibiotic treatment, but without repeat x-rays. Ultimately, he developed osteomyelitis, requiring multiple surgeries and a long hospital stay due to the retained foreign bodies. The commentary highlights the importance of evaluating patient risk of wound infection and poor wound healing, the role of imaging modalities to help identify foreign material in wounds, and diligent follow-up to prevent complications.
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.
This Month’s Perspectives
Interview
<p><span>Carole Stockmeier, Sarah Mossburg, Lee Merton</span></p><p> </p> |
Carole Stockmeier, MHA, BS, is the Senior Vice President of Safety and Reliability Solutions at Press Ganey, with over 20 years of experience in safety science and high reliability organizations. We spoke to her about zero harm and patient safety.
Interview
<p>Eric Thomas, Sarah Mossburg, Merton Lee</p> |
Eric Thomas, MD, MPH, is the Director of the University of Texas Houston Memorial Hermann Center for Healthcare Quality and Safety and is Associate Dean for Healthcare Quality. We spoke to him about zero harm and patient safety.
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