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September 25, 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
Adra I, Giga S, Hardy C, et al. J Safety Res. 2024;90:181-191.
Leadership commitment to safety strongly influences staff commitment to safety. This review sought to identify definitions and themes of "safety leadership." Three themes were derived from the definitions: 1) safety leadership improves safety performance; 2) safety leaders lead by influence and example, not authority; and 3) safety leadership can be practiced by leaders at all levels of the organization. Transformational and transactional leadership formed the foundation for many definitions, though the authors advise adopting multiple forms of leadership styles. The authors propose that future research focus on the relationship between leadership style and safety climate.
Angelilli S. AORN J. 2024;120(2):71-81.
Retained surgical items (RSI) are a never event. This article describes implementation of an evidence-based improvement project to reduce RSI and increase reporting of RSI near misses. An important aim was to improve teamwork and assertive communication between operating room (OR) team members, which was achieved through use of the TeamSTEPPS program. Change in staff attitudes about teamwork was measured using the Teamwork Attitudes Questionnaire, which showed improved perceived teamwork.
Braiki R, Douville F, Gagnon M‐P. Int J Nurs Pract. 2024;30(6):e13299.
Underreporting of adverse events and near misses results in incomplete data for patient safety improvement efforts. This review sought to identify factors contributing to nurses' decisions to report medication errors and near misses. The main factor contributing to decision-to-report is the expected reaction of superiors, colleagues, and patients. Fear of retaliation or poor grades prevented reporting by nurses and nursing students, respectively.
Spence MC, Sugarman A, Uong A, et al. Acad Pediatr. 2024;24(6):1010-1016.
Residency training is a challenging experience, requiring residents to balance demanding educational requirements and clinical duties. This study explored whether implementation of an academic half-day (AHD) as part of residency training impacts education, patient safety, and workflow. AHDs offer protected time for education (without clinical duties) on specific days, providing both social and educational benefits. Survey data indicate positive changes in resident attitudes and experiences after AHD implementation. No negative impacts on patient safety were identified.
Johnson J, Brown C, Lee GM, et al. Jt Comm J Qual Patient Saf. 2024;50(12):877-881.
Voluntary incident reporting is an important resource for identifying adverse events and near misses, but the volume of reports can pose challenges. This study used the large language model (LLM) ChatGPT-3.5 in a secure environment to label a sample of obstetric incident reports (e.g., neonatal resuscitation supplies, lactation support). Compared with the human-assigned labels—the gold standard—ChatGPT demonstrated high sensitivity and specificity.
Clark CM, Guan J, Patel AR, et al. J Am Geriatr Soc. 2024;72(9):2807-2815.
People taking potentially inappropriate medications (PIM) are at increased risk for adverse events, particularly those aged 65 and older. This study looked at the association between PIM prescription and self-reported health-related quality of life (HRQoL) of adults aged 65 and older. People taking at least one PIM reported lower HRQoL than those with no PIM.
Raban MZ, Fitzpatrick E, Merchant A, et al. J Am Med Inform Assoc. 2025;32(1):105-112.
Health information technology has positively impacted many aspects of patient care, but technology-related errors (TREs) still threaten patient safety. Set at one pediatric hospital in Australia, this retrospective study evaluated technology-related prescribing errors associated with computerized provider order entry (CPOE) over a four-year period. One-year post-CPOE implementation, researchers found that TRE rates decreased by 40%; however, rates returned to pre-CPOE levels after four years.
Miller S, Stockwell DC. J Patient Saf. 2024;20(7):e92-e96.
Patients who experience patient safety events may suffer physical, emotional, psychological, and financial consequences. Using an electronic trigger tool, researchers in this study evaluated financial impacts among patients who experienced harm events versus similar patients who did not across 37 acute-care facilities in three states. Patients who experienced preventable harm had longer length of stay and higher costs compared to patients who did not experience harm despite similarities in demographics and comorbidities in the two patient groups.
Dijkstra-Eijkemans RI, Knap LJ, Elbers NA, et al. BMC Health Serv Res. 2024;24(1):1044.
After an adverse event, the way hospitals involve families plays a significant role in the families' perspectives of the event. In this study, patients and family members affected by a serious adverse event, client (family) council representatives, and one national representative shared their perspectives on inclusion of patients and families in the official investigation. Important themes included respecting the patient's decision to be involved in the investigation or not, communicating to the patient what was learned so that the error will not happen again, and taking responsibility for the error.
Sangal RB, Khidir H, Agarwal AK. JAMA Health Forum. 2024;5(8):e242347.
In a busy emergency department, individuals may rely on heuristics that unknowingly undermine equitable care. This commentary highlights how actions such as selection of patient care queuing and subjective decision-making can be generated by implicit racial biases. The authors suggest triage protocols and partnering with patients to design process solutions.
Zimolzak AJ, Wei L, Mir U, et al. JAMA Netw Open. 2024;7(9):e2431982.
Machine learning (ML) has the potential to improve diagnosis and reduce adverse events in healthcare. This study evaluated an ML-enhanced electronic trigger to identify possible missed opportunities in diagnosis (MODs) among a large cohort of VA patients discharged from the emergency department (ED) after presenting with dizziness or abdominal pain who were subsequently hospitalized soon thereafter. Both ML-enhanced trigger tools had high positive predictive value, indicating that the tool could reduce the burden of manual medical record review to identify MODs
Fall F, Hu YY, Walker S, et al. J Pediatr Surg. 2024;59(9):1665-1671.
Nearly all healthcare providers report experiencing an error or adverse event and many of them endorse peer support as helpful. This article describes a peer support program for pediatric surgeons. The main reasons for seeking support were adverse events and toxic work environments. While only 15 referrals were made in the first year, the program appears feasible to develop and sustain to support struggling surgeons.
Angelilli S. AORN J. 2024;120(2):71-81.
Retained surgical items (RSI) are a never event. This article describes implementation of an evidence-based improvement project to reduce RSI and increase reporting of RSI near misses. An important aim was to improve teamwork and assertive communication between operating room (OR) team members, which was achieved through use of the TeamSTEPPS program. Change in staff attitudes about teamwork was measured using the Teamwork Attitudes Questionnaire, which showed improved perceived teamwork.
Ladell MM, Yale S, Bordini BJ, et al. BMJ Qual Saf. 2024;33(12):823-828.
Systems Engineering Initiative for Patient Safety (SEIPS) 101 model is a sociotechnical framework that characterizes the interactions of work system factors, processes, and outcomes. This article describes how one tool within the SEIPS 101 model— the People, Environment, Tools and Tasks (PETT) scan— assists patient safety investigators to identify the sociotechnical systems factors and their interactions in diagnostic error cases.
Braiki R, Douville F, Gagnon M‐P. Int J Nurs Pract. 2024;30(6):e13299.
Underreporting of adverse events and near misses results in incomplete data for patient safety improvement efforts. This review sought to identify factors contributing to nurses' decisions to report medication errors and near misses. The main factor contributing to decision-to-report is the expected reaction of superiors, colleagues, and patients. Fear of retaliation or poor grades prevented reporting by nurses and nursing students, respectively.
Adra I, Giga S, Hardy C, et al. J Safety Res. 2024;90:181-191.
Leadership commitment to safety strongly influences staff commitment to safety. This review sought to identify definitions and themes of "safety leadership." Three themes were derived from the definitions: 1) safety leadership improves safety performance; 2) safety leaders lead by influence and example, not authority; and 3) safety leadership can be practiced by leaders at all levels of the organization. Transformational and transactional leadership formed the foundation for many definitions, though the authors advise adopting multiple forms of leadership styles. The authors propose that future research focus on the relationship between leadership style and safety climate.
No results.
Newspaper/Magazine Article
Fleisher LA, Edmondson AC. MedPage Today. September 17, 2024;
The ability to learn-by-doing in an environment that is psychologically safe supports rapid innovation that can lead to improvement. This article advocates for the design and adoption of new approaches to enhance patient safety that build on what was learned during the COVID-19 pandemic that improved performance to provide care during challenging times.
Rodrick D, Timashenka A, Umscheid C. Rockville, MD: Agency for Healthcare Research and Quality; 2024. AHRQ Publication no. 24-0084
In-hospital adverse events provide a window into the state of patient safety. A new analysis of AHRQ Quality and Safety Review System (QSRS) data shows that hospitalized Medicare patients have experienced a decline in adverse events since the peak of the COVID-19 pandemic, with a 13% to 15% reduction in adverse events in 2022 compared to 2021. The analysis showed that in 2022, 6.2% of Medicare patients experienced at least one adverse event per hospital stay, a reduction from 7.1% in 2021.
Newspaper/Magazine Article
Coon R, Holden K. Pharmaceutical Journal. September 2024;313(7989).
Prescription errors have the potential to cause harm to patients. This article examines challenges to safe prescribing by pharmacists through a human factors lens. It highlights methods for applying this approach to safety work considering the built environment, personal status, technologies, and task complexities that affect and individual’s ability to prescribe.
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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