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October 2, 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
Nguyen OT, Kunta AR, Katoju SV, et al. JAMA Netw Open. 2024;7(9):e2432760.
Electronic health record (EHR) nudges are a common way to subtly change clinician behavior (e.g., prompt for immunizations). This review summarizes the association between EHR nudges and health outcomes in primary care. Results show nudges improve specific aspects of healthcare quality, but most studies reported only process measures—whether the nudge was accepted— not the impact on patient safety.
Prior A, Taylor I, Gibson KS, et al. J Clin Med. 2024;13(17):4973.
Patient safety bundles have been shown to improve patient safety. This article describes the 2022 revisions to the Alliance for Innovation on Maternal Health's Severe Hypertension in Pregnancy patient safety bundle. Updates include a broader focus on educating pregnant patients to recognize and respond to hypertensive emergencies and improved transitions of care.
Razick D, Amani N, Ali L, et al. Am J Med Qual. 2024;39(5):251-255.
Public reporting can support the identification and tailoring of patient safety improvement efforts. Using data from the Leapfrog Safety Grade database, this study explores the relationship between hospital characteristics (e.g., geographic location, size, and system affiliation) and performance ratings among 284 California hospitals. Findings suggest that urban hospitals, smaller hospitals, and hospitals not affiliated with a larger health system were more likely to have lower safety performance scores.
Sullivan JL, Shin MH, Ranusch A, et al. Jt Comm J Qual Patient Saf. 2024;50(11):791-800.
In 2019, the Veterans Health Administration (VHA) implemented a high reliability organization (HRO) strategy to improve care delivery and patient safety. This mixed methods study compared qualitative data from key informants at four VHA sites with quantitative data from a large patient safety culture (PSC) survey of VHA employees across two years. The researchers found that qualitative data aligned with most PSC survey domains but identified significant variation across sites.
Cornelison BR, Erstad BL, Edwards C. J Am Pharm Assoc (2003). 2024;64(4):102110.
Patients frequently use search engines to find information about symptoms, health conditions, and medications and are now turning to AI chatbots such as ChatGPT. In this study, ChatGPT-3.5 was prompted with questions patients may ask about the top 20 prescribed medications, such as side effects or interactions. Responses were rated for completeness and accuracy. Ninety-seven percent were completely or mostly accurate, and 81% were comprehensively complete.
Mirtallo JM, Allen P, Book WM, et al. Nutr Clin Pract. 2024;39(5):1164-1181.
Like many medications, parenteral nutrition is prone to supply shortages. In this study, patients and caregivers were surveyed about supply and access issues related to home parenteral nutrition (HPN). Most respondents had experienced or were aware of a product shortage in the last two years, including ingredients, tubing, and infusion pumps. Shortages resulted in changes in symptoms or exacerbation of disease for two-thirds of respondents. In addition to supply issues, lack of qualified healthcare providers and poor insurance reimbursement were noted to hinder access.
Giardina TD, Vaghani V, Upadhyay DK, et al. J Gen Intern Med. 2025;40(4):773-781.
The accuracy of the electronic health record (EHR) is crucial to receiving safe care. In this study, patients identified as at-risk for diagnostic errors were asked to review their most recent visit notes and indicate any diagnostic concerns. In 467 patients, 51 identified a concern, typically related to communication issues, accuracy of the clinical notes, and feeling like the clinician was not taking them seriously (e.g., wrongly attributed symptoms to weight or mental health). Physician chart reviewers identified diagnostic concerns in 31 cases, of which only 11 were also identified by patients.
Razick D, Amani N, Ali L, et al. Am J Med Qual. 2024;39(5):251-255.
Public reporting can support the identification and tailoring of patient safety improvement efforts. Using data from the Leapfrog Safety Grade database, this study explores the relationship between hospital characteristics (e.g., geographic location, size, and system affiliation) and performance ratings among 284 California hospitals. Findings suggest that urban hospitals, smaller hospitals, and hospitals not affiliated with a larger health system were more likely to have lower safety performance scores.
Raab C, Gambashidze N, Brust L, et al. BMC Health Serv Res. 2024;24(1):1052.
Engaging patients in safety efforts is a laudable goal, but engagement efforts are not always successful. Understanding patient motivations to engage in safety work is crucial to facilitating their involvement. This study interviewed and surveyed patients, providers, and managers on their motivations for patient engagement in patient safety. All three groups were motivated by a desire to actively improve delivery of health care. Patients were motivated to improve care and experiences for themselves and future patients and to express gratitude.
Watson J, Duncan P, Burrell A, et al. BMJ Open Qual. 2024;13(3):e002632.
Failure to communicate test results in a timely manner can lead to delayed or missed diagnoses. Using data from 2,572 patients across 57 general practices in the United Kingdom, this study audited the process for filing, actioning, and communicating blood test results. The researchers found that nearly half of patients (47%) had no documented evidence of blood test result communication in the electronic health record (EHR), even for abnormal results.
Morrissey LK, Ho P, Ilowite M, et al. Pediatr Qual Saf. 2024;9(5):e755.
Falls with injury are a never event. This article describes a multipronged improvement effort to reduce falls in a pediatric hospital. The intervention included enhanced communication with families and staff about fall risks, physical therapy to reduce deconditioning, and completion of apparent cause analysis for all falls with injury.
Graudins LV, Crute S, Poole SG, et al. Contemp Nurse. 2024;Epub Aug 8.
Reducing missed medication doses is an important patient safety effort. This article describes the impact of electronic medication management (EMM) systems and automated dispensing cabinets (ADC) on missed medication doses. Thirty months after implementation of EMM systems, preventable time-critical missed doses were reduced, with further reductions in units with ADC.
Cox C, Hatfield T, Fritz Z. BMJ Qual Saf. 2024;33(12):769-779.
Patients who visit the emergency department (ED) or urgent care may receive instructions to return to care if symptoms persist or new symptoms arise ("safety-netting"), particularly in cases of diagnostic uncertainty. In this study, internal medicine physicians were asked what they would tell a typical patient in three scenarios of diagnostic uncertainty. Safety-netting was common, but the specific content and recommended actions varied, and few physicians explicitly mentioned diagnostic uncertainty.
Tokede B, Yansane A, Walji MF, et al. J Patient Saf. 2024;20(7):454-460.
Patient safety in dentistry is relatively understudied compared to many other healthcare settings. This study examined the incidence and characteristics of adverse events occurring at two dental clinics. Among 5,033 patients, 1.4% had experienced an adverse event, most of which were mild or moderate and involved pain or hard tissue damage.
Lounsbury O, Brant K, Stockwell DC. J Patient Saf Risk Manag. 2024;29(3):128-130.
Safety-I and Safety-II are often seen as conflicting models for understanding medical failure and informing improvement. This article challenges siloing the two approaches and instead argues that they be merged to be successfully utilized to generate patient safety action and success.
Prior A, Taylor I, Gibson KS, et al. J Clin Med. 2024;13(17):4973.
Patient safety bundles have been shown to improve patient safety. This article describes the 2022 revisions to the Alliance for Innovation on Maternal Health's Severe Hypertension in Pregnancy patient safety bundle. Updates include a broader focus on educating pregnant patients to recognize and respond to hypertensive emergencies and improved transitions of care.
Nguyen OT, Kunta AR, Katoju SV, et al. JAMA Netw Open. 2024;7(9):e2432760.
Electronic health record (EHR) nudges are a common way to subtly change clinician behavior (e.g., prompt for immunizations). This review summarizes the association between EHR nudges and health outcomes in primary care. Results show nudges improve specific aspects of healthcare quality, but most studies reported only process measures—whether the nudge was accepted— not the impact on patient safety.
No results.
Rockville, MD: Agency for Healthcare Research and Quality; September 2024. AHRQ Publication No. 24-0087
Sepsis is a known safety concern that can result in substantial patient harm, in-hospital mortality, and costs if diagnosis and treatment are delayed. This report shares AHRQ’s comprehensive federal analysis of Healthcare Cost and Utilization Project (HCUP) data, which summarizes national trends, disparities, and variations linked with sepsis-associated hospital utilization, morbidity, and costs.
Multi-use Website
Centers for Disease Control and Prevention.
Diagnostic excellence is an expansion of the diagnostic error reduction movement that encompasses a range of quality and safety activities. This effort highlights six structural elements for driving improvement in diagnostic processes, including leadership commitment and accountability, patient engagement, and multidisciplinary diagnostic teams. Assessment tools and a medical test checklist are available to aid in prioritization of improvement work and in-patient/medical team communication.
Chicago, IL: American Hospital Association; September 2024.
Tracking hospital improvements can illustrate effective strategies for promoting patient safety and achieving organizational resilience. This report analyzed a set of patient safety measures in 1,300 hospitals and found that in the first quarter of 2024, hospitalized patients had improved survival rates and decreased CLABSI and CAUTI episodes compared to pre-pandemic levels. Screening rates for some cancers have also improved.
Audiovisual Presentation
Yang J, Surana K. PBS News Hour. 2024.
Poorly implemented and communicated policy can affect the ability of clinicians to provide safe care and patients to seek it. This news segment discusses two ProPublica articles exploring how delayed procedural care and medication access workarounds result in preventable maternal death associated with pregnancy complications.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Garth Utter, MD |
A 38-year-old man sustained multiple injuries in a motorcycle crash, including head trauma, chest injuries, and spinal fractures. Attempts to intubate him to manage his respiratory distress were unsuccessful and he underwent emergency cricothyroidotomy. Despite initial neurological evaluations indicating normal extremity movements, he developed progressive paralysis of his lower extremities over the hospital course. A delayed MRI revealed a significant epidural hematoma compressing his spinal cord from C3 to C7, prompting emergency surgery. Despite decompression, he suffered permanent paralysis. The commentary highlights the cognitive pitfalls associated with managing and processing large volumes of clinical information and the importance of effective communication and active engagement among all clinical team members.
WebM&M Cases
Spotlight Case
Ryan Martin, MD, FCNS and Kiarash Shahlaie, MD, PhD, FAANS, FCNS |
A man in his mid-50s presented to the hospital with a persistent headache after a sledding injury. A head CT scan was read as normal and he was diagnosed with a minor head injury and discharged without any specific treatment. Three weeks later, he presented with ongoing symptoms including worsening cognition and increased headache and was diagnosed with post-concussive syndrome and discharged without specific treatment. He was later diagnosed with a large frontal subdural hematoma requiring urgent surgery. The commentary discusses risk factors for delayed acute subdural hematoma and the importance of repeat brain imaging in patients with risk factors and persistent symptoms.
WebM&M Cases
Victoria Jackson, DNP, RN, PHN, FNP-C, PA-C and Anna Satake, PhD, MSN, GCNS, RN |
These cases involve two elderly patients presenting to the emergency department (ED) who suffered falls during their care, despite recognition of risk factors including previous ground-level falls. The commentary summarizes risk factors for fall injuries among high-risk populations (such as older adults), appropriate use of fall assessment and prevention strategies, and strategies to improve communication between healthcare team members to reduce the risk of patient falls.
This Month’s Perspectives
Interview
Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd |
Elizabeth Salisbury-Afshar, MD, MPH, is an Associate Professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health and Medical Director of the Compass Program, a low-barrier walk-in clinic for substance-related health concerns.
Perspective
Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd |
This piece provides an overview of the philosophy of harm reduction, as well as specific strategies for how it can improve safety for people who use substances.
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