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September 18, 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

Campione JR, Liu H. BMC Health Serv Res. 2024;24(1):955.
Electronic health record (EHR) design and usability can affect patient safety. This study used data from the 2017 AHRQ Surveys on Patient Safety Culture® (SOPS®) Hospital Survey Version 1.0 Database and the SOPS Health Information Technology Patient Safety Supplemental Items  to assess staff perceptions of EHR safety and usability by staff position and tenure. Pharmacists gave more unfavorable scores to EHR usability compared to nurses. Staff who were employed less than one year were more likely to report worse EHR training, and those employed more than 10 years were most dissatisfied with the EHR overall.
Cooper AS. Nurs Adm Q. 2024;48(3):248-252.
Falls and falls with injury are significant sources of morbidity and mortality and can have substantial negative impact on organizational finances. Fall Tailoring Interventions for Patient Safety (Fall TIPS) is an evidence-based program that engages patients in their own fall prevention program. This study showed  that after implementing the Fall TIPS program, falls and falls with injury decreased in several hospital units resulting in a return on investment of $982,700.
Gangopadhyaya A. J Patient Saf. 2024;20(8):e135-e141.
Patients from disadvantaged groups (e.g., patients of color, low income, non-English speaking) experience poorer medical outcomes. This study used hospital discharge data from nearly 2.1 million discharges for Medicaid and privately insured patients. Patients with Medicaid were more likely to be younger, Black or Hispanic, living in low-income neighborhoods, and have more comorbidities than patients with private insurance. When compared with privately insured patients, Medicaid patients experienced significantly higher rates of pressure injuries, catheter-related infections, and six-out-of-seven surgery-related safety indicators. This held true when adjusted for patient demographics, comorbidities, and location.
Vogt K S, Baker J, Kendal S, et al. Int J Mental Health Nurs. 2024;33(6):2227-2238.
Psychological safety in mental health settings is relatively understudied compared to other settings and clinical areas. In this study, researchers interviewed 12 former inpatient mental health service users in the United Kingdom about their perspectives on psychological safety in inpatient mental health settings. Participants reported more frequently feeling psychologically unsafe than safe. Psychological safety was influenced by factors such as staff attitudes, degree of control of their environment and medical decision-making, and physical safety.
Khan A, Baird JD, Mauskar S, et al. Pediatrics. 2024;154(4):e2023065245.
Parents of children with medical complexity (CMC) are experts in their child's needs and can provide invaluable safety information. In this pre-post study, English- and Spanish-speaking parents of CMC were asked to report safety concerns via paper survey (pre) or mobile app (post). Overall reporting rates did not change with the mobile app, but reporting did increase among parents with lower educational attainment. Only 15% of parent-reported safety concerns were also reported by staff.
Gangopadhyaya A. J Patient Saf. 2024;20(8):e135-e141.
Patients from disadvantaged groups (e.g., patients of color, low income, non-English speaking) experience poorer medical outcomes. This study used hospital discharge data from nearly 2.1 million discharges for Medicaid and privately insured patients. Patients with Medicaid were more likely to be younger, Black or Hispanic, living in low-income neighborhoods, and have more comorbidities than patients with private insurance. When compared with privately insured patients, Medicaid patients experienced significantly higher rates of pressure injuries, catheter-related infections, and six-out-of-seven surgery-related safety indicators. This held true when adjusted for patient demographics, comorbidities, and location.
Poranen A, Kouvonen A, Nordquist H. Scand J Trauma Resusc Emerg Med. 2024;32(1):78.
Advancing patient safety in prehospital care is receiving increasing attention. This qualitative study analyzed factors contributing to human errors among paramedics and emergency medical field supervisors in Finland. Researchers identified three main categories of contributing factors: (1) the changing work environment, such as external disruptions or challenging working conditions; (2) the organization of the work, such as inadequate care guidelines; and (3) individual factors, such as cognitive processing and individual needs.
Campione JR, Liu H. BMC Health Serv Res. 2024;24(1):955.
Electronic health record (EHR) design and usability can affect patient safety. This study used data from the 2017 AHRQ Surveys on Patient Safety Culture® (SOPS®) Hospital Survey Version 1.0 Database and the SOPS Health Information Technology Patient Safety Supplemental Items  to assess staff perceptions of EHR safety and usability by staff position and tenure. Pharmacists gave more unfavorable scores to EHR usability compared to nurses. Staff who were employed less than one year were more likely to report worse EHR training, and those employed more than 10 years were most dissatisfied with the EHR overall.
Van Wilder A, Bruyneel L, Cox B, et al. Health Aff. 2024;43(9):1274-1283.
The AHRQ Patient Safety Indicators (PSIs) are important metrics commonly used to assess patient safety in inpatient settings. This study used the PSIs to measure adverse events in over 4.7 million patient stays between 2016 and 2018 in Belgium. The researchers found that rates were generally low, but higher than comparable rates in the United States, particularly for failure-to-rescue and CLABSI. Only four PSIs had lower rates in Belgium compared to the United States.
Cooper AS. Nurs Adm Q. 2024;48(3):248-252.
Falls and falls with injury are significant sources of morbidity and mortality and can have substantial negative impact on organizational finances. Fall Tailoring Interventions for Patient Safety (Fall TIPS) is an evidence-based program that engages patients in their own fall prevention program. This study showed  that after implementing the Fall TIPS program, falls and falls with injury decreased in several hospital units resulting in a return on investment of $982,700.
Adams MA, Bevan C, Booker M, et al. Health Soc Care Deliv Res. 2023;12(22):1-159.
Following adverse events, many patients and families welcome disclosure from their providers about what happened. This study describes provider, patient, and family experiences of open disclosure following adverse events in maternity care provided in the English National Health Service (NHS). Patients and families wanted to play a more active role in the investigation and receive better communication. Providers reported needing dedicated time to talk to families and emotional support for staff who provide open disclosure.
McDonald KM, Gleason KT, Jajodia A, et al. Int J Health Policy Manag. 2024;13:8048.
Patient-reported measures (PRM) can improve the diagnostic process by incorporating perspectives from patients and caregivers. In this study, researchers used human-centered design principles, information from environmental scans, and expert workgroups to create “roadmaps” for developing feasible and usable PRMs that can support diagnostic excellence. This iterative process identified seven diagnostic excellence goals that can be achieved with PRMs. Sample roadmaps (illustrating the development and implementation of the PRMs to achieve diagnostic excellence goals) are also presented.
Bearman G, Nori P. Am J Med. 2024;137(8):694-697.
The role of leaders in patient safety should focus on both internal and external learning, achievement, and recognition to motivate effort and reduce opportunities for burn-out. This commentary cautions against overemphasizing one environment over the other and calls for leadership to balance their efforts to drive broad-based improvement.
Graber ML, Castro GM, Danforth M, et al. Diagnosis (Berl). 2024;11(4):353-368.
Root cause analysis (RCA) is a widely used approach to retrospectively analyze safety events like surgical complications or medication administration errors. This article proposes RCA as an approach to analyzing diagnostic errors. While the five overarching steps of RCA for cases involving diagnostic error are similar to standard RCA (e.g., convening the appropriate team members), the authors detail important differences. System 1 and System 2 thinking, human factors, and cognitive biases are discussed. A related handbook provides detailed instructions for conducting an RCA on diagnostic errors.
Lampe D, Grosser J, Grothe D, et al. BMC Med Inform Decis Mak. 2024;24(1):188.
Clinical decision support systems (CDSS) are designed to improve decision-making by providing information or recommendations relevant to a specific patient at the point of care. This review summarizes and categorizes CDSS outcomes in primary and long-term care. Almost all studies reported process-related outcomes (e.g., alert rates/overrides), approximately two-thirds were randomized controlled trials, and only three of 32 were conducted in long-term care. More research should be conducted using randomized controlled trials instead of pre-post studies and in long-term care settings.
Gustafsson M, Silva V, Valeiro C, et al. Pharmaceuticals (Basel). 2024;17(8):1009.
Even when opioids are appropriately prescribed, some patients may end up abusing or misusing them. In this review, studies on opioid abuse, misuse, or medication errors were analyzed. The most frequently mentioned opioids were morphine, fentanyl, and oxycodone. Adverse events occurred across the medication process including prescribing, dispensing, and administration. Rates of abuse and misuse varied across countries, typically due to drug availability.
No results.
Washington DC: Veterans Affairs Office of Inspector General; July 2024. Report No. 23-02958-203
This investigation from the VA Office of Inspector General (OIG) reviewed a patient care delay in receiving basic life support services while on VA medical center grounds, who later died at another facility. Explorations into causal factors determined policy inconsistency, equipment unavailability, and training gaps as problematic. At the system level leadership response and poor incident analysis and reporting negated improvement opportunities that align with the high reliability organizational attainment goals of the VA.
Tran AK, Syed Q, Bierman AS, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2024. AHRQ Publication No. 24-0010-7-EF
Few initiatives have examined the evidence on understanding and reducing diagnostic errors in older adult populations, particularly with the objective of identifying improvement opportunities. This issue brief presents the current evidence base, considerations and challenges of studying and improving diagnostic safety for older adults and provides strategies for new diagnostic error reduction efforts. This publication is part of a series of issue briefs related diagnostic safety.

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

Carole Stockmeier photo
Interview
<p><span>Carole Stockmeier, Sarah Mossburg, Lee Merton</span></p><p>&nbsp;</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.
Eric Thomas photo
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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