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October 30, 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
Andrikyan W, Sametinger SM, Kosfeld F, et al. BMJ Qual Saf. 2024;Epub Oct 1.
Patients frequently use the internet, and now chatbots, to learn more about their health, symptoms, or medications. This study queried Microsoft's Bing chatbot, Copilot, about the 50 most frequently prescribed and over-the-counter medications. Drug.com's patient information was used for the reference database. Mean completeness was 76.7%, and mean accuracy was 88.7%. Experts evaluated a subset of 20 questions and found approximately half aligned with scientific consensus.
Browning S, Raleigh RA, Hattingh HL. Int J Clin Pharm. 2024;Epub Sep 30.
Transitions of care present challenges, such as loss of information or misunderstandings, that can negatively impact patient safety. This study explored how residential aged care facilities (RACF) manage medications when residents enter the facility from a hospital. The authors state that a resident discharged from the hospital to RACF ideally receives a supply of new or changed medications, a hard copy of a discharge summary, an interim medication administration record (IMAR), and, if discharged from the ED, an Emergency Department Discharge Medication Administration Record. Responses from 31 RACF demonstrated these practices vary widely, with less than half always receiving an IMAR and one-third always receiving a hard copy of the discharge summary.
Tsamasiotis C, Fiard G, Bouzat P, et al. Risk Manag Healthc Policy. 2024;17:1847-1858.
Morbidity and Mortality Conferences (MMCs) and Experience Feedback Committees (EFCs) are two strategies to support individual and organizational learning from adverse events. This study, conducted at one French hospital, examined whether MMCs and EFCs improve patient safety culture among healthcare professionals. Findings suggest that participation in MMCs and EFCs improves certain aspects of safety culture (error response, organizational learning), but systemic challenges, such as staffing and leadership support, hinder widespread improvements.
Plugge T, Breviu A, Lappé K, et al. Am J Med Qual. 2024;39(4):168-173.
Medical students and residents have lower rates of error reporting than other staff groups. As a result, medical schools now include curricula on identifying system failures and reporting them through existing reporting structures. This study assessed 5 years of medical student descriptions of adverse events, whether they felt an incident report was required, and their rationale for not submitting one. Students indicated that only 18% of adverse events would require reporting, with a common rationale of no harm reaching the patient, i.e., a near miss.
Andrikyan W, Sametinger SM, Kosfeld F, et al. BMJ Qual Saf. 2024;Epub Oct 1.
Patients frequently use the internet, and now chatbots, to learn more about their health, symptoms, or medications. This study queried Microsoft's Bing chatbot, Copilot, about the 50 most frequently prescribed and over-the-counter medications. Drug.com's patient information was used for the reference database. Mean completeness was 76.7%, and mean accuracy was 88.7%. Experts evaluated a subset of 20 questions and found approximately half aligned with scientific consensus.
Chen Y, Power MC, Grodstein F, et al. Alzheimers Dement. 2024;20(8):5551-5560.
As the number of older adults continues to increase, so will the number of cases of dementia. Timely diagnosis ensures these patients and their caregivers receive appropriate treatment and support. This study utilized five longitudinal research cohorts to estimate timely diagnosis of clinical dementia, defined as a clinical diagnosis 3 years before or 1 year after the date of cohort evaluation at which a participant’s symptom of dementia was noted for the first time. Only half of older adults with incident dementia diagnosed within the research study received a timely clinical diagnosis of dementia. Black older adults and those with lower income, higher baseline cognitive functioning, and fewer comorbidities were at increased risk of delayed diagnosis.
Tsamasiotis C, Fiard G, Bouzat P, et al. Risk Manag Healthc Policy. 2024;17:1847-1858.
Morbidity and Mortality Conferences (MMCs) and Experience Feedback Committees (EFCs) are two strategies to support individual and organizational learning from adverse events. This study, conducted at one French hospital, examined whether MMCs and EFCs improve patient safety culture among healthcare professionals. Findings suggest that participation in MMCs and EFCs improves certain aspects of safety culture (error response, organizational learning), but systemic challenges, such as staffing and leadership support, hinder widespread improvements.
Browning S, Raleigh RA, Hattingh HL. Int J Clin Pharm. 2024;Epub Sep 30.
Transitions of care present challenges, such as loss of information or misunderstandings, that can negatively impact patient safety. This study explored how residential aged care facilities (RACF) manage medications when residents enter the facility from a hospital. The authors state that a resident discharged from the hospital to RACF ideally receives a supply of new or changed medications, a hard copy of a discharge summary, an interim medication administration record (IMAR), and, if discharged from the ED, an Emergency Department Discharge Medication Administration Record. Responses from 31 RACF demonstrated these practices vary widely, with less than half always receiving an IMAR and one-third always receiving a hard copy of the discharge summary.
Girnius A, Snyder C, Czarny H, et al. Anesth Analg. 2024;139(6):1199-1209.
After a staff survey demonstrated dissatisfaction with team communication prior to unscheduled (but not emergent) cesarean deliveries, this labor and delivery unit implemented a bedside, multidisciplinary pre-cesarean delivery huddle involving anesthesia, nursing, and obstetrics teams. The huddle ensured direct communication, shared understanding of urgency, and clear role assignments. Staff survey results showed increased satisfaction with communication following implementation of the huddle.
Kim U, Rose J, Carroll BT, et al. JAMA Netw Open. 2024;7(10):e2439263.
The COVID-19 pandemic disrupted cancer screening and diagnostic visits. This study reports the difference between observed and expected cancer rates in 2020 and 2021 in the United States. The percentage difference between the expected and observed cancer rates in 2020 was -8.6%, but largely recovered in 2021 (-0.2% difference). Recovery rates varied by patient demographics (e.g., rural location) and cancer site. A cumulative deficit of more than 127,000 patients still exists, presenting a concern for a surge of patients presenting with more advanced disease in upcoming years.
Shambhu S, Gordon AS, Liu Y, et al. Jt Comm J Qual Patient Saf. 2024;50(12):857-866.
Surgical site infections (SSIs) are a common source of preventable harm following surgery. In this retrospective claims-based study, researchers examined the impact of SSI infections after coronary artery bypass graft (CABG), bariatric surgery (BS), or certain orthopedic procedures. Findings indicate that patients with SSI infections had longer hospital stays, higher readmission rates, and higher medical costs compared to a matched cohort without SSI. Patients with SSI after orthopedic procedures had significantly higher 12-month mortality compared to patients without SSI.
Thurgood Giarman A, Hays HL, Badeti J, et al. Inj Epidemiol. 2024;11(1):51.
Errors in the administration of diabetes medications can result in emergency department visits, hospitalizations, and patient harm. Using National Poison Data System data, researchers found that errors involving diabetes medications administered outside of healthcare facilities increased by nearly 280% from 2000 to 2011 and by 15% from 2011 to 2021. About 10% of those errors involved a serious outcome (e.g., hospital admission or death). Insulin-related errors were most common, but metformin accounted for 59% of deaths.
Singh H, Senay E, Sherman JD. J Hosp Med. 2024;19(11):1071-1076.
Healthcare pollution (e.g., medical waste, water pollution, emissions from healthcare-related facilities or transport) is receiving increasing attention as contributing to climate change and patient harm. This article discusses how foundational principles in patient safety—accountability, data transparency, and public reporting—can further evidence-based environmental sustainability initiatives in health care.
Kilbourne AM, Borsky AE, O'Brien RW, et al. Health Serv Res. 2024;Epub Aug 20.
Learning health systems (LHS) build functions, networks, and processes to use data, information, evidence, and knowledge to implement change and, ultimately, sustain improvements. This commentary proposes an updated scientific agenda for funding agencies to support LHS to align research with healthcare organization and Quintuple Aim goals. It describes research topics within each foundational method (implementation, data, engagement, systems, and policy sciences) and their benefits to end-users.
Talcott W, Covington E, Bazan J, et al. Semin Radiat Oncol. 2024;34(4):433-440.
Radiation oncology represents a complex care process involving a multidisciplinary team and can present patient safety challenges. This article summarizes practices to advance the quality and safety of radiation oncology, including incident learning systems, safety culture, and second victim support. The authors also discuss how artificial intelligence applications in radiation oncology can advance safe care and introduce new safety challenges.
Hill MA, Coppinger T, Sedig K, et al. J Patient Saf. 2024;20(8):529-534.
Patients are encouraged to ask questions during the diagnostic process, and numerous organizations and agencies offer patient-facing question prompt lists (QPL) to support patient-provider communication. In this review, more than 5,500 questions were identified from QPL. Most lists were intended for specific health conditions (e.g., cancer), with most questions related to treatment options. Lists contained 3 to 113 questions, with an average of 21, which the authors state is likely too many to be addressed in a 10- to 20-minute ambulatory visit.
No results.
Newcastle Upon Tyne, UK: Care Quality Commission; September 2024.
Maternal safety is a global public health concern. This report details maternity care in the NHS between August 2022 and December 2023. Only 4% of the 131 inspected locations were rated as outstanding, and 48% were rated as good. Areas for improvement include risk assessment and triage, recruitment and retention of staff, estates (units) and environment, inequalities and racism, and communication with women and families.
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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