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June 19, 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

Guirguis-Blake JM, Perdue LA, Coppola EL, et al. JAMA. 2024;Epub Jun 4.
Falls are a leading cause of injury and death in adults aged 65 years and older, and prevention is a public health and patient safety priority. This review of interventions to prevent falls in community-dwelling older adults was conducted for the US Preventive Services Task Force (USPSTF). Multifactorial and exercise interventions were associated with reduced falls, with exercise interventions demonstrating the most consistent benefit.
Menezes MS, Doria GAA, Valença-Feitosa F, et al. Explor Res Clin Social Pharm. 2024;14:100435.
High-risk medications are classified as such due to their narrow therapeutic range and potential for serious adverse drug events (ADE). This review analyzes the results of randomized clinical trials to identify effective interventions to reduce ADE related to high-risk medications in hospitals. The most cited medications were warfarin, cyclophosphamide, and cyclosporine. The most common intervention was developing protocols for safe use.
Pimentel MPT, Chung S, Ross JM, et al. Anesth Analg. 2024;Epub Apr 19.
An increasing proportion of surgeries are performed in freestanding ambulatory surgery centers (ASCs) rather than in hospitals. This study examined closed anesthesia-related malpractice claims of ASCs and hospital-based operating rooms (HORs) to examine any differences in severity of injury, major injuries, allegations, comorbidities, contributing factors, and financial value of the claim. The most common type of injury in both ASC and HOR was dental injury followed by nerve damage. Claims with higher severity of injury were less frequent in ASCs compared to HORs, but patient burns and poor communication between patients and providers were more frequent issues among ASC claims.
Van der Voorden M, Franx A, Ahaus K. BMC Health Serv Res. 2024;24:700.
Patient engagement in patient safety efforts is widely encouraged, but prior research has identified negative consequences from patient participation. This qualitative study with patients and maternity care professionals in the Netherlands explored actions to mitigate negative effects of patient participation in safety, including transparency, shared decision-making, and patient-centered culture
Pimentel MPT, Chung S, Ross JM, et al. Anesth Analg. 2024;Epub Apr 19.
An increasing proportion of surgeries are performed in freestanding ambulatory surgery centers (ASCs) rather than in hospitals. This study examined closed anesthesia-related malpractice claims of ASCs and hospital-based operating rooms (HORs) to examine any differences in severity of injury, major injuries, allegations, comorbidities, contributing factors, and financial value of the claim. The most common type of injury in both ASC and HOR was dental injury followed by nerve damage. Claims with higher severity of injury were less frequent in ASCs compared to HORs, but patient burns and poor communication between patients and providers were more frequent issues among ASC claims.
Allaudeen N, Schalch E, Neff M, et al. Jt Comm J Qual Patient Saf. 2024;Epub Apr 26.
Patient safety indicators (PSIs) are designed to assess the frequency, severity, and impact of measurable harm in healthcare. In this study, one Veterans Affairs (VA) hospital implemented three clinical care and two accurate data capture interventions to improve rates of the composite PSI-90 and three individual PSIs (pressure ulcers, postoperative PE/DVT, and postoperative sepsis). Postoperative PE/DVT, postoperative sepsis, and composite PSI-90 all decreased, while pressure ulcer rates increased.
Harada Y, Suzuki T, Harada T, et al. BMJ Open Qual. 2024;13:e002654.
ChatGPT and other large language models are being studied for their ability to provide correct diagnoses in numerous clinical areas. This study sought to evaluate ChatGPT's ability to identify diagnostic errors in case studies. ChatGPT was able to identify diagnostic errors in 95% of the 545 case reports. The results suggest ChatGPT could be used to screen for possible diagnostic errors in electronic health records, but significant research and testing is still required.
Westbrook JI, Li L, Woods AL, et al. Drug Saf. 2024;47:545-556.
Medication administration errors remain a common source of preventable harm for hospitalized patients. This prospective observational study of 298 pediatric nurses at one hospital in Sydney, Australia, found that errors occurred in one-third of medication administrations. Intravenous injections had highest rate of potentially serious errors (59.7%) followed by intravenous infusions (10.5%). The analysis identified several significant risk factors for medication administration errors, including intravenous route, weekend administration, and use of electronic medication management systems.
Abdullayev K, Gorvett O, Sochiera A, et al. BMJ Open. 2024;14:e080445.
Better understanding of the challenges faced by patients and clinicians in the diagnostic pathway can ensure development of appropriate diagnostic technologies. In this study, patients with lived experience of cardiovascular disease (CVD) and clinicians described their experiences and challenges in coming to an accurate diagnosis. Patients and clinicians described symptom interpretation, patient characteristics, patient-clinician interaction, and systemic challenges as all contributing to difficulty in getting a timely CVD diagnosis. Considerations to reduce these diagnostic challenges are presented along with ways technology can be utilized for further reductions.
Ginzberg SP, Gasior JA, Passman JE, et al. JAMA Netw Open. 2024;7:e2414329.
Adverse events in surgery can lead to catastrophic patient harm, so understanding the support needs of surgeons following these events is a high priority. Women and racially minoritized surgical trainees reported more negative effects than men and white trainees. Trainees and faculty reported talking to a peer or mentor was helpful in managing the negative effects, and no faculty mentioned using professional mental health services.
Wang Y, Ram S (S), Scahill S. J Patient Saf. 2024;20:e18-e28.
A myriad of factors can increase the risk for medication errors. This thematic analysis of 37 published complaints against pharmacists in New Zealand explored the role of individual, organizational, system, medication-specific, and environmental factors contributing to medication errors. The findings highlight the importance of considering environmental and system factors, in addition to individual performance issues, to address and prevent medication errors.
Alfred M, Barg-Walkow LH, Keebler JR, et al. BMJ Qual Saf. 2024;Epub May 2.
Checklists are ubiquitous across healthcare. This article describes an algorithm to guide development or refinement of checklists including how to decide if a checklist is the most effective intervention and what type of checklist would be most effective. The authors stress that end users should be involved in the design process.
Handley JL, Lehmann CU, Ratwani RM. JAMA Pediatr. 2024;Epub May 13.
Accepting shared responsibility for improvement is core to safe care. This commentary submits that the use of artificial intelligence (AI) to support equitable health care for children requires development and evaluation efforts involving multiple stakeholders to embed ethical design and use requirements into AI systems for the pediatric patient population.
Menezes MS, Doria GAA, Valença-Feitosa F, et al. Explor Res Clin Social Pharm. 2024;14:100435.
High-risk medications are classified as such due to their narrow therapeutic range and potential for serious adverse drug events (ADE). This review analyzes the results of randomized clinical trials to identify effective interventions to reduce ADE related to high-risk medications in hospitals. The most cited medications were warfarin, cyclophosphamide, and cyclosporine. The most common intervention was developing protocols for safe use.
Guirguis-Blake JM, Perdue LA, Coppola EL, et al. JAMA. 2024;Epub Jun 4.
Falls are a leading cause of injury and death in adults aged 65 years and older, and prevention is a public health and patient safety priority. This review of interventions to prevent falls in community-dwelling older adults was conducted for the US Preventive Services Task Force (USPSTF). Multifactorial and exercise interventions were associated with reduced falls, with exercise interventions demonstrating the most consistent benefit.
Coleman BC, Rubinstein SM, Salsbury SA, et al. Chiropr Man Therap. 2024;32:15.
Human error affects activities in all types of care professions. This commentary seeks to motivate patient safety improvement in chiropractic practice. It organizes its approach on the elements of the WHO Global Patient Safety Action Plan to position the field to reduce preventable patient harm and instill a culture of safety throughout the profession.
Sehgal A. Br J Hosp Med (Lond). 2024;85:1-9.
Organizational incident reporting systems are an important tool to identify, and learn from, adverse events and errors in health care. This article highlights the strengths of reporting and learning systems (e.g., the opportunity to learn from near-miss events), limitations (e.g., under- or over-reporting), and factors influencing use of these systems (e.g., safety culture, feedback). 
No results.

Dorset, UK: Health Services Safety Investigations Body; May 2024

Acute mental health care fosters unique challenges for both adult and pediatric patients. This report examines elements of the physical care environment that affect patient safety for children and adolescents receiving mental health care. It encourages organizations to explore opportunities to modify hospital and ward structures to design safety into room layout and features.

This Month’s WebM&Ms

WebM&M Cases
Spotlight Case
Elizabeth Gould, NP-C, CORLN, Krystal Craddock, BSRC, RRT, RRT-ACCS, RRT-NPS, AE-C, CCM, Tyler Le Tellier, RRT, Brooks T Kuhn, MD, MAS |
A 55-year-old man with a history of osteoarthritis and supraventricular tachycardia was admitted the hospital with severe COVID-19 and required endotracheal intubation and invasive mechanical ventilation. Following transfer to a long-term care hospital (LTCH) for continued weaning from mechanical ventilation, inadequate tracheostomy management protocols were evident, with no specific instructions provided. Subsequently, the patient experienced respiratory distress and cardiac arrest due to a blocked tracheostomy tube, highlighting critical deficiencies in care and communication. The commentary summarizes the risk factors for tracheostomy complications, the importance of tracheostomy tube maintenance and monitoring, and strategies to safeguard tracheostomy tube care during transitions of care. 
WebM&M Cases
Sharmilee Vuyyuru, DO, and Nandakishor Kapa, MD |
A 57-year-old man was rushed to the Emergency Department from a nursing facility, struggling to breathe. With a history of hypertension, diabetes, and heart failure, his vital signs were concerning, showing high blood pressure, rapid heart rate, and low oxygen levels. Examinations revealed fluid buildup in his lungs and legs, indicating severe heart and kidney problems. Despite attempts to remove excess fluid with medication, dialysis became necessary. However, a complication arose during catheter insertion, requiring emergency surgery to retrieve a misplaced guidewire.
WebM&M Cases
Spotlight Case
Andrew P.J. Olson, MD, FACP, FAAP |
Five weeks after gastric bypass surgery, a woman experienced persistent nausea and vomiting, leading to dehydration and multiple outpatient treatments. Despite visiting an outpatient clinic and emergency department (ED) for ongoing symptoms and significant weight loss, the nausea and vomiting persisted. Eventually, she was admitted to the ICU with pancreatitis and dehydration. Subsequently, she exhibited neurological symptoms including difficulty walking, tingling sensations, and cognitive impairment. She was discharged with orders for total parenteral nutrition (TPN). Three days after discharge, she was readmitted for worsening confusion and profound motor weakness, which progressed to respiratory failure requiring mechanical ventilation. Laboratory tests revealed an extremely low thiamine level, and the patient was diagnosed with advanced Wernicke-Korsakoff Syndrome, exacerbated by a lack of proper nutrition, and resulting in permanent brain damage, necessitating ongoing care. The commentary discusses how biases associated with medical conditions, such as obesity and its treatment, can lead to poorer outcomes, as well as strategies to continually re-evaluate diagnostic reasoning in light of ongoing, intensive management and management reasoning
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