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January 15, 2025 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

Alrowily A, Alfaraidy K, Almutairi S, et al. Explor Res Clin Soc Pharm. 2025;17:100531.
Errors involving high-risk medications have the potential to cause serious harm or death. In this study, incident reports from the UK's National Reporting and Learning System involving three high-risk medications—opioids, insulin, and anticoagulants—were analyzed to determine the nature and types of errors as well as contributing factors. Around half of errors for each type of medication occurred at administration. 97% of errors resulted in low or no harm. Despite the encouraging results, the authors note the importance of continuing to improve the quality of incident reports to yield better learning opportunities to improve medication safety.
Ao HS, Matthews T. Patient Safety. 2024;6(1):123603.
Diagnostic errors account for a significant proportion of malpractice lawsuits and payouts. In 20 years of closed malpractice claims, diagnostic errors comprised 26.6% of cases, 39% of which resulted in death. Failure to diagnose and delay in diagnosis were the most common specific allegation types. Overall, diagnosis-related allegations trended downward; however, inpatient allegations trended upward. Payment was higher for men than women, suggesting an area for further research.
Martínez-Nicolas I, Arnal-Velasco D, Romero-García E, et al. BJS Open. 2024;8(6):zrae143.
Adherence to evidence-based practices and clinical guidelines is essential to the delivery of safe, high quality healthcare. This systematic review of 267 clinical guidelines identified 4,666 perioperative patient safety recommendations for adults, with 45% considered strong recommendations. However, the authors noted that only a small subset of recommendations met high methodological standards and identified a gap in pre-admission and post-discharge care recommendations.
Ao HS, Matthews T. Patient Safety. 2024;6(1):123603.
Diagnostic errors account for a significant proportion of malpractice lawsuits and payouts. In 20 years of closed malpractice claims, diagnostic errors comprised 26.6% of cases, 39% of which resulted in death. Failure to diagnose and delay in diagnosis were the most common specific allegation types. Overall, diagnosis-related allegations trended downward; however, inpatient allegations trended upward. Payment was higher for men than women, suggesting an area for further research.
Hartman V, Zhang X, Poddar R, et al. JAMA Netw Open. 2024;7(12):e2448723.
Suboptimal handoffs are associated with increased risk of adverse events. In this study, a large language model (LLM) was designed and used to draft notes for handoff from the emergency department to inpatient services. Compared to physician-written notes, LLM-generated notes included higher detail but slightly lower usefulness and patient safety scores. None of the LLM-generated handoff notes were considered a critical patient safety risk.
Alrowily A, Alfaraidy K, Almutairi S, et al. Explor Res Clin Soc Pharm. 2025;17:100531.
Errors involving high-risk medications have the potential to cause serious harm or death. In this study, incident reports from the UK's National Reporting and Learning System involving three high-risk medications—opioids, insulin, and anticoagulants—were analyzed to determine the nature and types of errors as well as contributing factors. Around half of errors for each type of medication occurred at administration. 97% of errors resulted in low or no harm. Despite the encouraging results, the authors note the importance of continuing to improve the quality of incident reports to yield better learning opportunities to improve medication safety.
Graber ML, Winters BD, Matin R, et al. Diagnosis (Berl). 2024;Epub Oct 18.
Cancer is one of the "Big Three" misdiagnosis-related harms in malpractice claims. This integrative review of missed opportunities to diagnose cancer identified "closing the loop" as a cross-cutting theme to improve timely diagnosis. Closing the loop includes better communication with the patient at the initial encounter, structured communication between the ordering provider and radiology, and closer follow-up with patients after abnormal test results.
Butler LR, Lashani S, Mitchell C, et al. Front Health Serv. 2024;4:1419248.
The Agency for Healthcare Research and Quality Surveys on Patient Safety Culture™ (SOPS®) are used for assessing patient safety culture and can show trends when completed at multiple points in time. This study uses an innovative approach to analyze Hospital SOPS results longitudinally by calculating the difference between positive and negative responses (Delta). Results of the Delta analysis were similar to the traditional scoring method (percent of positive responses) and allowed for a more thorough understanding of survey results.
Gilson AM, Chladek JS, Stone JA, et al. J Patient Saf. 2024;21(1):38-47.
Unintentional misuse (e.g., drug-drug, drug-age interactions) of over-the-counter (OTC) medications can result in significant patient harm, particularly for high-risk populations, such as older adults. In this study, community pharmacies participating in the intervention redesigned pharmacy aisles to support older adults' selection of safe OTC medications (Senior Safe); control pharmacies did not make any design changes. Consumers age 65 or older at participating pharmacies were asked to read a hypothetical health scenario, select an OTC from inside the pharmacy, and then describe how they would use it. Drug-drug and drug-age misuse types were more common at control pharmacies for high-risk medications.
Martínez-Nicolas I, Arnal-Velasco D, Romero-García E, et al. BJS Open. 2024;8(6):zrae143.
Adherence to evidence-based practices and clinical guidelines is essential to the delivery of safe, high quality healthcare. This systematic review of 267 clinical guidelines identified 4,666 perioperative patient safety recommendations for adults, with 45% considered strong recommendations. However, the authors noted that only a small subset of recommendations met high methodological standards and identified a gap in pre-admission and post-discharge care recommendations.
Geiselman EL, Opsahl A, Townsend C. J Prof Nurs. 2024;55:105-111.
A just culture ensures that staff feel safe reporting errors without fear of reprisal or retaliation. This article describes an educational activity for nursing students to help them understand the legal and ethical consequences of medical errors and error reporting using the RaDonda Vaught case as an exemplar. After the activity, students reported greater understanding of error reporting, the role of state boards of nursing, system failures, and just culture.
Abdelaziz S, Garfield S, Neves AL, et al. BMJ Open. 2024;14(11):e089026.
While advanced technologies improve patient safety in many ways, there are often unintended consequences. When patients, carers, and healthcare providers describe potential patient safety consequences of technology in health care, five themes emerge: inequity of access, increased end-user burden, loss of the human element of health care, over-reliance on technology, and unclear responsibilities. A novel finding was the potential "gaming" of technology wherein a patient enters falsified data to suggest a worsening condition and get an earlier appointment, possibly delaying treatment for another patient.
Kotwal S, Udayappan KM, Kutheala N, et al. J Gen Intern Med. 2024;39(16):3271-3277.
Feedback on the diagnostic process can improve clinical reasoning and improve diagnostic safety. This study evaluated satisfaction with an e-feedback system for hospitalists (focused on care escalation episodes). Satisfaction among participating hospitalists was high. Qualitative analysis of feedback surveys highlighted the value of learning about patient outcomes, detailed feedback, and reflecting on clinical decision-making.
Alfandre D, Foglia MB, Holodniy M, et al. Jt Comm J Qual Patient Saf. 2025;51(2):159-163.
While large-scale adverse events (LSAEs) are rare, healthcare organizations must maintain policies on LSAE disclosure (LSAED) should they occur. This article provides an analytic framework for healthcare organizations to consider in the event of an LSAE. The process begins with identification of the LSAE, followed by determination of justifiability of disclosure, determination of requisite effort for notification, and execution of notification plan.
Lee E, De Gagne J C, Randall P S, et al. J Adv Nurs. 2024;Epub Nov 4.
Psychological safety and confidence in speaking up about safety concerns are essential characteristics of a culture of safety. This qualitative metasynthesis reviewed 15 studies to explore nurses’ experiences of speaking up. The analysis identified barriers to speaking up, such as hierarchical structures and poor work environment, as well as factors supporting speaking up, such as interprofessional responsibility and a supportive atmosphere.
No results.
Agency for Healthcare Quality and Research. Special Emphasis Notice. December 20, 2024;Publication No. NOT-HS-25-012.
Emergency department boarding and overcrowding can contribute to unsafe care. This announcement highlights AHRQ’s interest in funding research and innovations that address the problem. Care omission, treatment delay, and staff distraction illustrate topics covered by this notice.
Measurement Tool/Indicator
Agency for Healthcare Quality and Research. 2024.
Maternal health care faces a variety of patient safety challenges. This set of quality indicators supports the epidemiological or research program use of billing or claims data to measure severe maternal morbidity. The data can be applied to inform the development of population-level improvement strategies and track trends in severe maternal morbidity.
Int J Public Health. 2024;69.
The importance of creating healthcare environments that enable concerns to be voiced and support individuals who err is an international concern. This special issue examines a range of elements that impact psychological safety in health care. Articles discuss topics such as peer support, second victims, safety climate, and speaking up.
Food and Drug Administration. January 06, 2025;
Pulse oximeters are known to be less accurate on persons of color, creating the potential for unsafe care. This draft guidance shares regulatory recommendations to improve the performance and appropriate labeling of pulse oximeters to improve its safe use throughout health care. The comment submission process will close on March 10, 2025.

This Month’s WebM&Ms

WebM&M Cases
Spotlight Case
Jaenic Lee, MD, Josh Fernelius, MD and William Frick, MD |
A 55-year-old woman with a history of panic attacks, obesity, and untreated hypertension, experienced syncope after feeling flushed and lightheaded. On arrival at the emergency department, she had severely elevated blood pressure and hypoxemia. Diagnostic tests revealed acute heart failure exacerbation with pulmonary edema, marked elevation of brain natriuretic peptide (BNP), and elevated troponin-I. Despite treatment with diuretics and antihypertensives, her condition deteriorated, leading to intubation due to respiratory failure and subsequent cardiac arrest; cardiopulmonary resuscitation resulted in with return of spontaneous circulation. However, she suffered from ischemic stroke and intracranial hemorrhages, ultimately leading to a transition to comfort care and subsequent death. The commentary discusses the contraindications for beta-blockers in the setting of acute decompensated heart failure and appropriate treatment for hypertensive emergencies in the emergency department and intensive care unit. 
WebM&M Cases
Spotlight Case
Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Lewis, MD |
A 54-year-old man with a history of tobacco use presented to the emergency department (ED) with acute chest pain. He was initially stable upon arrival, though with signs of fluid overload and electrolyte abnormalities including hyponatremia and hyperkalemia. Despite treatment including heparin, amiodarone, and metoprolol for atrial fibrillation, and interventions for hyperkalemia, the patient deteriorated rapidly into cardiac arrest characterized by Torsades de pointes, which was mistaken for ventricular fibrillation. Despite resuscitative efforts, he did not achieve return of spontaneous circulation and autopsy revealed sudden cardiac arrest without myocardial infarction as the cause of death. The commentary highlights how the misinterpretation of a common laboratory complication can lead to incorrect treatment and patient harm.
WebM&M Cases
Spotlight Case
Jonathan A. Edlow, MD, FACEP |
A patient in his mid-30s presented to the emergency department (ED) with three weeks of intermittent left-sided headaches, balance issues, and one brief episode of difficulty speaking and moving. On exam, the patient had normal vital signs, neurologic exam, and initial imaging; he was discharged from the ED without consultation from neurology. A few hours later, he suffered a stroke due to left posterior cerebral artery occlusion and vertebral artery dissection, leading to severe neurological deficits after delayed treatment. The commentary highlights the importance of thorough neurological investigation of patients presenting with dizziness and other simultaneous neurological symptoms, the challenges of diagnosing transient ischemic attack (TIA) – particularly in a young, healthy adult, and the limitations of non-contrast brain CT for identifying TIA or early ischemic strokes in patients presenting with dizziness. 

This Month’s Perspectives

Patricia Dykes headshot
Interview
Patricia Dykes, PhD, MA, RN, FAAN, FACMI, Zoe Sousane, BS, Sarah E. Mossburg, RN, PhD |
Dr. Patricia Dykes is the Program Director for Research at the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital and a Professor of Medicine at Harvard Medical School. We spoke with her about falls and fall prevention.
Perspective
Patricia Dykes, PhD, MA, RN, FAAN, FACMI, Zoe Sousane, BS, Sarah E. Mossburg, RN, PhD |
This piece discusses the continuing challenge of preventing falls and explores strategies for preventing falls and falls with injury in both inpatient and outpatient settings.
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