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November 13, 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
Goh E, Gallo R, Hom J, et al. JAMA Netw Open. 2024;7(10):e2440969.
Large language models (LLM) offer a promising approach to improving diagnostic accuracy. In this study, internal medicine physicians were randomized to use conventional (eg, UpToDate) or conventional plus LLM diagnostic resources to provide a differential and final diagnosis on 4 to 6 clinical vignettes. There was no significant difference in diagnostic performance or time spent per case between conventional and conventional plus LLM groups; LLM alone performed 16% better than the control group.
Juhl MH, Soerensen AL, Vardinghus-Nielsen H, et al. JMIR Form Res. 2024;8:e54977.
Residents of nursing homes (NH) often require multiple medications to treat their chronic conditions. This article describes the co-creation of an intervention to improve medication safety in Danish nursing homes. Unlicensed healthcare personnel who administer the medication (social and healthcare assistants and helpers) and relatives representing NH residents contributed to the design of the intervention. The Safe Medication in Nursing Home Residents (SAME) intervention includes materials to define key roles and responsibilities for healthcare professionals and "medication safety reflexive spaces," a series of facilitated sessions.
Shalviri G, Mohebbi N, Mirbaha F, et al. Cochrane Database Syst Rev. 2024;2024(10):CD012594.
Adverse drug events (ADE) are common medical errors that can lead to additional healthcare utilization and patient harm. This Cochrane review, including 15 studies with over 62,000 participants, evaluated the effectiveness of interventions to improve ADE reporting. The review found low-certainty evidence that education sessions paired with reminder cards and ADE report forms can significantly improve reporting rates. The review found uncertain or very low-certainty evidence on the effectiveness of other inventions (eg, linking to ADE reporting in the EHR, government regulations with financial incentives).
Zubkoff L, Zimolzak AJ, Meyer AND, et al. JAMA Netw Open. 2024;7(10):e2440269.
Failure to follow up on test results promptly can lead to delayed diagnoses. This article describes an evaluation of a quality improvement collaborative to improve follow-up on commonly missed test results related to lung and colorectal cancer across 12 VA medical centers. In the study, 11 teams implemented 47 unique interventions, including increased patient engagement through access to test results and preventing EHR notification fatigue. Researchers identified improvements in follow-up rates for abnormal test results at sites with the lowest baseline performance but did not find significant improvements across study sites overall.
Tsilimingras D, Schnipper JL, Zhang L, et al. J Patient Saf. 2024;20(8):564-570.
Patients are vulnerable to patient safety events during care transitions between inpatient settings. This study found that over 22% of patients experienced adverse events (AE) during transitions of care between the emergency department (ED) and inpatient care at 2 urban hospitals. The researchers found that most AEs were preventable and commonly involved adverse drug events and diagnostic errors. AEs were more likely to occur among patients with longer ED stays.
Hall LH, Johnson J, Watt I, et al. PLoS ONE. 2024;19(8):e0307513.
Provider burnout has been increasing, particularly since the start of the COVID-19 pandemic, and numerous interventions are being investigated to reduce it. This study used daily diaries from primary care physicians to investigate the association between breaks during the workday and burnout, well-being, and patient safety perceptions. Results indicate that taking a break is associated with lower disengagement that day and lower exhaustion the next day. A break that includes a positive interaction also improves perceptions of patient safety.
Chan J, Nsumba S, Wortsman M, et al. NPJ Dig Med. 2024;7(1):287.
Medication errors in operating rooms are a persistent patient safety challenge. This article describes training and testing of an AI-enabled wearable camera designed to alert anesthesia providers to medication errors involving a drug vial or syringe. Syringe labels were correctly classified in 98.7% of events, and vials were correctly classified in 99.2%.
Citty SW, Chew M, Hiller LD, et al. Nutr Clin Prac. 2024;39(4):784-799.
Enteral nutrition (EN) therapies are vulnerable to the same types of errors as those occurring in the medication use process (ie, prescribing, transcribing/documenting, dispensing, administering, and monitoring). This study categorized 1,227 EN-related safety events reported to the Joint Patient Safety Reporting (JPSR) system. Three-quarters of reported events were classified as "care management events," eg, incorrect rate or dosage; 31% of errors occurred during administration; and 28% occurred during monitoring.
Goh E, Gallo R, Hom J, et al. JAMA Netw Open. 2024;7(10):e2440969.
Large language models (LLM) offer a promising approach to improving diagnostic accuracy. In this study, internal medicine physicians were randomized to use conventional (eg, UpToDate) or conventional plus LLM diagnostic resources to provide a differential and final diagnosis on 4 to 6 clinical vignettes. There was no significant difference in diagnostic performance or time spent per case between conventional and conventional plus LLM groups; LLM alone performed 16% better than the control group.
Tartari E, Storr J, Bellare N, et al. BMJ Qual Saf. 2024;Epub Oct 4.
Hand hygiene is an important patient safety practice to prevent infection transmission. This article describes a global expert panel charged with developing consensus on research priorities on the role of institutional safety climate in the context of hand hygiene improvement strategies. The panel identified 31 priority research areas. Prioritized topics include the role of safety culture and media in shaping hand hygiene practices, the impact of the built environment, and barriers to, and enablers of, effective leadership support.
Lin DM, Lane-Fall MB, Lea JA, et al. Jt Comm J Qual Patient Saf. 2024;50(11):764-774.
Physical and nonphysical violence can negatively impact the work environment, increase rates of burnout, and lower perceptions of patient safety. This study details workplace violence experienced and witnessed by perioperative anesthesiologist assistants, certified registered nurse anesthetists, physicians, and registered nurses. More than three-quarters of participants reported having experienced or witnessed some form of workplace violence. Less than half reported satisfaction with how the organization addressed and resolved the situation. The most common sources of workplace violence were the patient or a family member, friend, or physician in the perioperative environment.
Main EK, Nath R, Bauer ME. Semin Perinatol. 2024:151976.
Maternal (or obstetric) sepsis is a leading cause of maternal morbidity and mortality; early identification and rapid response are vital. This report describes a patient-centered approach to diagnosis and treatment of maternal sepsis. Patient educational materials, a checklist to support patients following an adverse event, and standardized approaches to screening and diagnosis are detailed.
Juhl MH, Soerensen AL, Vardinghus-Nielsen H, et al. JMIR Form Res. 2024;8:e54977.
Residents of nursing homes (NH) often require multiple medications to treat their chronic conditions. This article describes the co-creation of an intervention to improve medication safety in Danish nursing homes. Unlicensed healthcare personnel who administer the medication (social and healthcare assistants and helpers) and relatives representing NH residents contributed to the design of the intervention. The Safe Medication in Nursing Home Residents (SAME) intervention includes materials to define key roles and responsibilities for healthcare professionals and "medication safety reflexive spaces," a series of facilitated sessions.
Commentary
Huson TA. JAMA Intern Med. 2024;184(11):1287-1288.
Equitable, safe health care is affected by myriad socioeconomic factors. This commentary describes a near miss involving a mother who was unable to share concerns about her infant’s health due to language barriers and the problems her covering physician encountered while advocating for her care.
Ali KJ, Ehsan S, Tran A, et al. Am J Med. 2024;137(11):1035-1041.
The relationship between health care and climate change is an emerging area of study. This review describes several ways climate change impacts diagnostic safety, such as the challenges associated with diagnosing new climate-related pathogens, and how overuse of low-value diagnostic tools contributes to high greenhouse gas emissions. Public health policies could encourage patients and providers to reduce low-value, high-emission diagnostic care by selecting only appropriate tests and treatments and support efforts to train providers on documenting climate-related diagnosis (e.g., sequela from heatwave).
Shalviri G, Mohebbi N, Mirbaha F, et al. Cochrane Database Syst Rev. 2024;2024(10):CD012594.
Adverse drug events (ADE) are common medical errors that can lead to additional healthcare utilization and patient harm. This Cochrane review, including 15 studies with over 62,000 participants, evaluated the effectiveness of interventions to improve ADE reporting. The review found low-certainty evidence that education sessions paired with reminder cards and ADE report forms can significantly improve reporting rates. The review found uncertain or very low-certainty evidence on the effectiveness of other inventions (eg, linking to ADE reporting in the EHR, government regulations with financial incentives).
No results.
Special or Theme Issue
Jaramillo C, Surana K, Presser L, et al. ProPublica. 2024:September - November 2024.
Healthcare policy decisions should be crafted and implemented with consideration of potential unintended consequences that can affect patient safety. This series examines the negative impact of abortion care limitations in the United States. It shares the stories of women and their families who have suffered harm due to lack of access to appropriate treatment.
Special or Theme Issue
Harbell MW, ed. Curr Opin Anaesthesiol. 2024;37(6):666-742.
Despite consummate efforts to improve safety, errors still occur in anesthesiology. This special collection covers a range of topics affecting safe care in the specialty, including pain management, incident reporting, psychological safety, and human factors.
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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