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October 16, 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

Al Abbas AI, Meier J, Daniel W, et al. Surg Endosc. 2024;38(10):5613-5622.
Compliance with and completeness of surgical safety checklists (SSC) remain difficult to measure. In this study, the Operating Room Black Box (ORBB) analyzed the performance of the OR team on the compliance, engagement, and quality of SSC completion, assigning a composite score. Operations performed by teams with better scores were associated with better postoperative outcomes, including reduced mortality and decreased ICU and general length of stay.
Labkoff S, Oladimeji B, Kannry J, et al. J Am Med Inform Assoc. 2024;Epub Sep 26.
Before being implemented into clinical practice, artificial intelligence-enabled clinical decision support (AI-CDS) requires careful evaluation. This article presents the consensus recommendations from an interdisciplinary workgroup on safe integration of AI-CDS. Key considerations include transparency, equity, monitoring, and user training.
Tubic B, Bånnsgård M, Gustavsson S, et al. J Patient Saf. 2024;20(7):490-497.
Patient engagement in health care can support detection of adverse events and delivery of safe care. This study assessed whether an illustrated educational pamphlet (in addition to verbal information) about patient safety risks for inpatients improved engagement in their care and reduced risk of adverse events. Patients who received both the illustrated pamphlet and verbal information reported significantly better perceptions of their care compared with patients who only received verbal information.
Pan D, Nilsson E, Rahman Jabin MS. Health Informatics J. 2024;30(3):3.
Health information technology (HIT) has led to improvements and efficiencies in patient care but has also introduced threats to patient safety. In this qualitative analysis, researchers explored factors contributing to HIT-related patient safety incidents in Swedish healthcare settings. About three-quarters of the 95 incidents studied were due to technical factors. Human factors accounted for 26% of incidents. Of all incidents, 20% led to patient harm.
Dalal AK, Plombon S, Konieczny K, et al. BMJ Qual Saf. 2024;Epub Oct 1.
To reduce diagnostic errors, an understanding of their current prevalence is necessary. In this random sample of patients hospitalized in general medicine, approximately 1 in 14 patients experienced a harmful diagnostic error, the majority of which were potentially preventable. Assessment, diagnostic test ordering, subspecialty consultation, patient experience, and history were significantly associated with harmful diagnostic errors.
Mujuru C, Peisah C. J of Healthc Risk Manag. 2024;Epub Sep 11.
Attitudes, behaviors, and relationships in health care influence the safety of patient care. This study aimed to identify systemic and relational human factors that contribute to serious adverse events. Root cause analysis investigation reports from two hospital districts were analyzed. Overarching themes included delays and inertia, with a subtheme of inertia of ageism; “all-or-nothing” approach to end-of-life care and planning; communication lapses; and implementation gap between standards and practice.
Al Abbas AI, Meier J, Daniel W, et al. Surg Endosc. 2024;38(10):5613-5622.
Compliance with and completeness of surgical safety checklists (SSC) remain difficult to measure. In this study, the Operating Room Black Box (ORBB) analyzed the performance of the OR team on the compliance, engagement, and quality of SSC completion, assigning a composite score. Operations performed by teams with better scores were associated with better postoperative outcomes, including reduced mortality and decreased ICU and general length of stay.
Tubic B, Bånnsgård M, Gustavsson S, et al. J Patient Saf. 2024;20(7):490-497.
Patient engagement in health care can support detection of adverse events and delivery of safe care. This study assessed whether an illustrated educational pamphlet (in addition to verbal information) about patient safety risks for inpatients improved engagement in their care and reduced risk of adverse events. Patients who received both the illustrated pamphlet and verbal information reported significantly better perceptions of their care compared with patients who only received verbal information.
Bergholtz J, Wolf A, Crine V, et al. BMJ Open. 2024;14(9):e083215.
Patients, caregivers, and the public are invaluable in the evaluation and delivery of health services. This systematic review of reviews summarizes patient and public involvement (PPI) in healthcare decision-making, including outcomes that are measured and gaps requiring further research. The review identified 37 systematic reviews on PPI in healthcare decision-making; three of these focused on PPI in patient safety and the others focused on healthcare quality improvement, community-based initiatives, peer support, and healthcare professional education. Adverse events, readmissions, and mortality were commonly studied outcomes in the identified reviews of PPI in patient safety.
Schulson L, Bandini J, Bialas A, et al. BMJ Open Qual. 2024;13(3):e002692.
The COVID-19 pandemic impacted nearly every aspect of healthcare delivery and threatened patient safety. Based on semi-structured interviews with 27 healthcare professionals from 16 hospitals in the United States, this study explored perspectives of frontline clinicians regarding patient safety during the COVID-19 pandemic. Participants highlighted two main issues: (1) compromised access to health care and delayed diagnosis and treatment due to increasing telehealth use and deferred care and (2) impaired care delivery due to staffing and equipment shortages and space constraints, causing healthcare-associated infections, medication errors, and other patient safety events.
Johnson TN, Tucker AM. Am J Health-Syst Pharm. 2024;Epub Sep 13.
Adverse events can negatively impact a provider's mental and physical health, leading to "second victim syndrome" (SDS). At one comprehensive cancer center, 37% of pharmacists, pharmacy technicians, and pharmacy staff reported experiencing SVS at least once in their lifetime, with nearly 10% reporting they never fully recovered. Time away from the unit, a peaceful location, and peer-to-peer assistance programs were the most desired support resources.
Alibhai KM, Zabolotniuk TR, Raîche I, et al. J Surg Educ. 2024;81(11):1637-1644.
Medical students and residents must consider several factors when deciding to contact more senior residents for guidance or assistance. General surgery senior residents (SR; 3rd to 5th year residents) and junior learners (JL; medical students, 1st and 2nd year residents) were presented with several clinical scenarios and asked if the JL should or would contact the SR. Both groups identified several patient- and learner-related factors that would influence the decision to contact the SR, such as the patient’s appearance or nurse's level of concern. Junior learners identified time of day and relationship with the senior resident as additional factors that would influence their decision.
Gonzalez AK, Butler JR. Obstet Gynecol Clin North Am. 2024;51(3):453-461.
Hospitalists are physicians who provide care only in acute care settings. This commentary outlines patient safety benefits of OBGYN hospitalists, such as decreased length of stay for patients, reduced cesarean delivery rates, and decreased preterm deliveries when compared to OBGYNs who provide both inpatient and outpatient care.
La Regina M, Federici L, Bianco A, et al. Int J Qual Health Care. 2024;36(3):mzae087.
Value-based health care is still evolving as a safety improvement strategy. This commentary describes how value-based care could improve safety, equity, and the patient-focus of care delivery. The authors posit that care teams should work to embed human factors engineering in the design of processes supporting care delivery to enhance value.
Sanders AA, Roberts JD, McDowell MC, et al. Soc Work Public Health. 2024;39(7):721-733.
Implicit biases and structural racism can impede the delivery of appropriate mental health care. This article summarizes the evidence on race-based trauma and the consequences of misdiagnosing trauma responses in Black men. The authors present a conceptual framework (incorporating historical trauma, discrimination, cultural competence, and public narratives) to improve equitable mental health assessment and treatment.
Labkoff S, Oladimeji B, Kannry J, et al. J Am Med Inform Assoc. 2024;Epub Sep 26.
Before being implemented into clinical practice, artificial intelligence-enabled clinical decision support (AI-CDS) requires careful evaluation. This article presents the consensus recommendations from an interdisciplinary workgroup on safe integration of AI-CDS. Key considerations include transparency, equity, monitoring, and user training.
No results.
No results.
Ali KJ, Galvez NJ, Craig S, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2024. AHRQ Publication No. 24-0010-9-EF
Rural patients and families can face a variety of challenges to receiving effective health care. This issue brief examines barriers that degrade the diagnostic process for this population. The authors specifically discuss care coordination, socioeconomic factors, and access to specialty care as elements that degrade safe diagnosis in rural environments. This report is part of an AHRQ series of issue briefs related to diagnostic safety.

Boston, MA: Institute for Healthcare Improvement; September 23, 2024.

Older adults experience diagnostic problems due to physiological and socioeconomic issues and implicit bias. This program will support eight healthcare organizations’ efforts to design and implement innovations that work to improve diagnostic processes for older adults. The online application submission due date is November 8, 2024.
Newspaper/Magazine Article
Lu-Boettcher YE, Koka R. APSF Newsletter. 39(3):84-86.
Medication safety is a primary concern during surgery, particularly when treating children. This newsletter article discusses pediatric perioperative medication errors and shares strategies for improving safety, including the use of prefilled syringes and barcode scanning.

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

Elizabeth_Salisbury-Afshar
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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