May 22, 2013 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.
Holdsworth M, Wittstrom K, Yeitrakis T. Ann Pharmacother. 2013;47(4):475-81.
The majority of state licensing boards pursue disciplinary action, such as license suspension, against pharmacists who are involved in medication errors. This occurs despite a consensus that such punitive measures are unlikely to improve patient safety.
Jothiraj H, Howland-Harris J, Evley R, et al. Br J Anaesth. 2013;111(3):477-82.
This study found that while distractions and interruptions were common for anesthesiologists, most of them had no appreciable effect on patient safety or clinical care.
Sibbald M, de Bruin A, van Merrienboer JJG. Adv Health Sci Educ Theory Pract. 2014;19(1):43-51.
Checklists have been shown to improve patient safety and clinical outcomes when used in combination with other interventions to increase adherence to proven safety strategies. The use of checklists to prevent diagnostic errors has been advocated as well. In this study, medical students, residents, and cardiology fellows were instructed to use a checklist while interpreting electrocardiograms (ECGs). Use of the checklist increased the accuracy of ECG interpretation for all groups and was most effective with the least experienced clinicians. As ECG interpretation errors are common and have serious clinical consequences, checklists such as this have the potential to improve patient care.
Catchpole K, Gangi A, Blocker RC, et al. J Surg Res. 2013;184(1):586-91.
Higher acuity trauma patients were more likely to experience disruptions in their care during transitions from the emergency department (ED) to the operating room or intensive care unit. The authors point out that the transition of patients from the ED to other hospital areas is a relatively understudied area of patient safety.
Huis A, Schoonhoven L, Grol R, et al. Int J Nurs Stud. 2013;50(4):464-74.
In this cluster randomized trial, a strategy that sought to improve nurses' hand hygiene by emphasizing team commitment and leadership engagement did achieve higher hand hygiene rates compared with a standard quality improvement approach. However, the overall rate of hand hygiene adherence remained poor in both groups.
Mitchell EL, Lee DY, Arora S, et al. Acad Med. 2013;88(6):824-30.
Reorganization of a surgical morbidity and mortality conference to focus on patient safety issues using the SBAR format improved both participants' knowledge and the quality of the conference.
Wang C-J, Fetzer SJ, Yang Y-C, et al. Geriatr Nurs. 2013;34(2):138-45.
The use of trained community volunteers resulted in improved medication safety knowledge and behaviors among elderly patients with chronic illness in a rural area. This study is notable as there is very little research on methods to augment patient safety in ambulatory care outside of urban settings.
Pincavage A, Lee WW, Beiting KJ, et al. J Gen Intern Med. 2013;28(8):999-1007.
The academic year-end transfer of primary care patients from graduating residents to their successors can pose risks to patients. This survey of patients within an academic primary care practice identifies the concerns patients have with the transfer process and the barriers in care they encounter as a result.
Acquaviva K, Haskell H, Johnson J. J Prof Nurs. 2013;29(2):95-101.
This commentary reviews the death of a patient to identify factors that contributed to the incident, including cognitive biases and poor communication between clinicians, and recommends strategies to address them.
Myers JS, Tess A, Glasheen JJ, et al. Am J Med Qual. 2014;29(1):5-12.
This commentary describes the development, implementation, and evaluation of a curriculum to enhance medical educators' quality improvement and patient safety teaching competencies.
Russ AL, Fairbanks RJ, Karsh B-T, et al. BMJ Qual Saf. 2013;22(10):802-8.
This commentary highlights elements of human factors that can be applied to improve efficiency and safety in health care.
Philibert I, Nasca TJ, Brigham T, et al. Annu Rev Med. 2013;64:467-83.
This review of high-quality studies found evidence for improved resident sleep hygiene and decreased burnout after restriction of duty hours, but no improvement in educational or patient safety outcomes.
Georgiou A, Prgomet M, Paoloni R, et al. Ann Emerg Med. 2013;61(6):644-653.e16.
Although use of computerized provider order entry (CPOE) is increasingly widespread, implementation in the busy environment of the emergency department (ED) is still relatively new. This systematic review of the effectiveness of CPOE in the ED found that, consistent with other systematic reviews, it did reduce medication prescribing errors. However, few studies assessed the effect of CPOE on clinician workflow, and there was no clear impact on patient safety. The unique patient safety issues in the ED are discussed in an AHRQ WebM&M perspective.
Niedner M, Muething S, Sutcliffe K. Pediatr Clin North Am. 2013;60(3):563-80.
This review describes how to apply concepts from high reliability organizations to pediatric critical care.
No results.
Newspaper/Magazine Article
Clark C. HealthLeaders Media. May 9, 2013.
This news piece reports on a national evaluation of hospitals that found little improvement in safety in the profiled health care systems.
Newspaper/Magazine Article
Boodman SG. Washington Post. May 6, 2013.
This newspaper article discusses the pervasive problem of diagnostic errors and reveals insights from clinicians and patients on why they occur and how to prevent them.
Special or Theme Issue
Holland K, ed. Nurse Educ Pract. 2013;13(2):e1-e87.
Articles in this special issue outline the development and outcomes of a 20-year initiative to improve medication dosage calculation in nursing education.
Dekker S. Boca Raton, FL: CRC Press; 2013. ISBN: 9781466583412.
This book covers how to investigate patient safety incidents while simultaneously providing support for second victims.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Joseph O. Jacobson, MD, MSc, and Saul N. Weingart, MD, PhD |
A cancer patient expecting to be discharged from the hospital after his usual 3-day regimen was surprised to hear that he has 2 more days of chemotherapy. He asked to speak with the oncology team, who discovered that although the right medications were ordered, the wrong duration and dosage were selected on the order set.
WebM&M Cases
B. Joseph Guglielmo, PharmD |
On multiple oral medications and a depot injection (dispensed by a separate specialty pharmacy and administered at a clinic), a patient with schizophrenia was mistakenly given the depot injection kit by his local pharmacy and injected it himself.
WebM&M Cases
Roy Ilan, MD, MSc |
A woman was emergently admitted for surgery for acute appendicitis. Although the patient had a chest port for breast cancer chemotherapy, the surgeon demanded that a peripherally inserted central catheter (PICC) be placed. The patient developed blood clots from the PICC, and surgery was cancelled. Significant complications, including perforation, peritonitis, and prolonged hospitalization, arose from managing the appendicitis conservatively.
This Month’s Perspectives
Interview
Harvard internist Dr. Jha is a national leader in policy issues related to safety and quality.
Perspective
Peter K. Lindenauer, MD, MSc |
This piece discusses efforts to promote the business case for safety and quality in health care.
