Sorry, you need to enable JavaScript to visit this website.
Skip to main content

January 7, 2015 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.

Weenink JW, Westert GP, Schoonhoven L, et al. BMJ Qual Saf. 2015;24(1):56-64.
In this survey study, one-third of respondents reported an experience with an impaired or incompetent colleague within the last year. One limitation to the survey findings was the low 28% response rate, but the authors note that even if all non-respondents had no such encounters, the results suggest at least 9% of health care professionals have dealt with impaired or incompetent colleagues.
Reames BN, Scally CP, Thumma JR, et al. Med Care. 2015;53(1):87-94.
The introduction of surgical safety checklists is often seen as a milestone accomplishment for the patient safety field, based on impressive reductions in mortality and complications shown in early international studies. More recently, a large trial in Ontario failed to show significant improvements following mandatory checklist adoption. However some concerns were raised related to methodological limitations, such as a lack of a comprehensive program for implementation. This study examined the effects of the Keystone Surgery program, a statewide effort in Michigan hospitals to introduce a surgical safety checklist along with a comprehensive unit-based safety program. Using Medicare claims data, no differences were found in adjusted 30-day mortality, complication rates, reoperations, or readmissions for hospitals participating in Keystone Surgery. Unlike the prior Ontario study, this study assessed outcomes up to 3 years following implementation and included a standardized and comprehensive implementation strategy. These results cast further doubt on the power of surgical safety checklists to improve outcomes when implemented in non-research settings.
Renkema E, Broekhuis MH, Ahaus K. J Eval Clin Pract. 2014;20(5):649-56.
Dutch physicians varied widely in their attitudes related to malpractice litigation. The relationship between attitudes and disclosure behaviors was not straightforward, but physicians with negative attitudes toward malpractice were more likely to express a reluctance to disclose incidents to patients.
Odukoya OK, Stone JA, Chui MA. Res Social Adm Pharm. 2014;10(6):837-852.
The handwritten prescription pad is vanishing from clinical practice, replaced by the proliferation of e-prescribing. There are many advantages to this technology, but prescribing errors still occur at alarming rates. This study explored the approaches community pharmacists and technicians utilize to detect and manage e-prescription errors.
Kemper PF, van Dyck C, Wagner C, et al. J Patient Saf. 2017;13(4):223-231.
Teamwork training has become a critical tool for promoting health care safety. This study describes the preparation, implementation, and impact of a crew resource management training program at three Dutch intensive care units. Following the training sessions, the participants launched several local quality improvement projects.
Donaldson N, Aydin C, Fridman M, et al. J Healthc Qual. 2014;36(6):58-68.
This cross-sectional study presents data collected from the Collaborative Alliance for Nursing Outcomes benchmarking registry. In this convenience sample, nurses deviated from medication administration safe practices approximately 11% per encounter, and administration errors occurred 0.32% per encounter. Distractions or interruptions accounted for nearly one-fourth of the safe practice deviations.
McAllister C, Leykum LK, Lanham H, et al. J Hosp Med. 2014;9(12):764-71.
Assessing more than 350 hours of direct observations, researchers found interpersonal relationships and behaviors of inpatient medicine teams were associated with complication rates for patients. The presence of trust, defined as a willingness to be vulnerable to others (e.g., an attending on rounds admitting "I don't know"), and the engagement of the entire team in discussions appeared to be particularly important aspects to ensuring patient safety, associated with decreased length of stay and complication rates. This study highlights the importance of relationships and social interactions between inpatient teams, and applies a rigorous analysis method for defining aspects of relationship characteristics. Poor team communication has previously been linked to patient harms in operating rooms and labor and delivery units.
Cahill TJ, Clarke SC, Simpson IA, et al. Heart. 2015;101(2):91-3.
Drawing from the success of the WHO surgical safety checklist initiative, this commentary describes the development of a checklist created to improve the reliability of core invasive cardiac procedures such as diagnostic angiography. The authors discuss the role of nurses in introducing the checklist and the use of team briefings to reduce the risk of communication errors. An example of the checklist tested is included.
Gooden R, Syed SB, Rutter P, et al. Community Dev J. 2013;49(4).
This commentary provides information about an approach to augment patient safety through public health engagement. Implemented in partnership with six African countries to spread and sustain safe care practices, the initiative utilized a seven-component model to bring together community leaders and hospitals to drive improvement. A recent AHRQ WebM&M perspective covered lessons learned throughout implementation of the program.
Keeys C, Kalejaiye B, Skinner M, et al. Am J Health Syst Pharm. 2014;71(24):2159-66.
Providing patients with an accurate list of their medication at discharge can be challenging. This commentary reveals the development, implementation, and initial testing of a service managed by pharmacists that engaged telepharmacy support as partners to enhance medication reconciliation at discharge. By the end of the 19-month pilot program, the service enhanced the quality of final medication lists and documentation given to patients at discharge.
Lyratzopoulos G, Wardle J, Rubin G. BMJ. 2014;349:g7400.
Past studies have found that delays in cancer diagnosis are common and harmful. Suggesting that such delays are not always due to error, this commentary reviews how diagnostic difficulty can lead to multiple consultations and hinder timely diagnosis of cancer in primary care.
Guise V, Anderson JE, Wiig S. BMC Health Serv Res. 2014;14:588.
Patient safety in the homecare setting has begun to garner increasing attention. This systematic review explored patient safety issues related to the emerging use of telecare to provide remote services for patients at home. Many risks were identified, but the authors conclude more study is needed to understand telecare-related patient safety.
Nguyen C, McElroy LM, Abecassis MM, et al. Int J Med Inform. 2015;84(2):101-10.
Pagers have been a mainstay for urgent clinician–clinician communication for many decades. Increasingly physicians are using a variety of electronic devices, including smartphones and Web-based technologies. This systematic review identified 16 articles that studied different technologies for urgent clinician communication. Each strategy had potential advantages and pitfalls. For example, smartphones are associated with decreased transmission time compared to pagers, but they also result in more clinician interruptions. There is very little evidence linking any specific communication method with benefits for patient care. Future study could more robustly explore which forms of communication are best for clinicians and patients. A prior AHRQ WebM&M commentary describes a case of serious patient harm related to a smartphone interruption.
No results.
Boonyasai RT, Ijagbemi OM, Pham JC, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 14(15)-0067-EF.
This report analyzes the literature discussing emergency department discharge processes and highlights elements of high-quality discharges and risk factors for suboptimal discharges. The in-depth review summarizes interventions currently implemented to augment discharge procedures, care coordination, and the identification of patients more susceptible to poor discharge.
Grissinger M, Alghamdi D. PA-PSRS Patient Saf Advis. December 2014;11:149-155.
Analyzing incidents reported over a 4-month period, this article reveals that 21% of 2700 medication errors involved at least one high-alert medication. The investigation found that more than half of errors occurred during the administration process, and problems associated with set up and use of intravenous (IV) delivery systems contributed to omissions. Recommended strategies to reduce risks include developing standard procedures, tracing IV lines, and enhancing utilization of health care technology.
Harvard Medical School, Boston, MA
The Institute of Medicine's learning health system concept serves as the foundation for this year-long curriculum covering how to apply change management, safety science, and informatics skills to the clinical setting for high-quality care. The program includes webinars, lectures, workshops, and case discussions. 

This Month’s WebM&Ms

WebM&M Cases
Spotlight Case
Mark W. Scerbo, PhD, and Alfred Z. Abuhamad, MD |
A woman who had an uncomplicated pregnancy and normal labor with no apparent signs of distress delivered a cyanotic, flaccid infant requiring extensive resuscitation. Although fetal heart rate tracings had shown signs of moderate-to-severe fetal distress for 90 minutes prior to delivery, clinicians did not notice the abnormalities on the remote centralized monitor, which displayed 16 windows, each for a different patient.
WebM&M Cases
Krishna Moorthy, MD, MS |
Following outpatient laparoscopic surgery to repair an inguinal hernia, a man with no significant past medical history had high levels of pain at the surgical site and was admitted to the hospital. With sustained pain on postoperative day 3, the patient developed tachycardia with abdominal distension and a low-grade fever. A CT scan revealed a bowel perforation, which required surgery and a lengthy ICU stay due to septicemia.
WebM&M Cases
John H. Eichhorn, MD |
While undergoing an elective coronary artery bypass graft (CABG) and ablation, an elderly man had a pulmonary artery catheter (PAC) placed to monitor his hemodynamic status. During the operation, the team was informed that another patient needed an emergency CABG. In the rush to attend to the second patient, the PAC in the first was left inflated for a prolonged period, which could have led to a catastrophic complication.

This Month’s Perspectives

Annual Perspective
Urmimala Sarkar, MD, and Kaveh Shojania, MD |
Computerized provider order entry is a cornerstone of patient safety efforts, and the increasingly widespread implementation of electronic health records has made it a standard practice in health care. This Annual Perspective summarizes novel findings and research directions in computerized provider order entry in 2015.
Interview
Mr. Graban is an internationally recognized expert in Lean Healthcare. We spoke with him about applying Lean in hospitals to improve safety and decrease waste.
Stay Updated!
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. Sign up today to get weekly and monthly updates via emails!