Email Updates
November 15, 2023 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
Arbaje AI, Greyson S, Keita Fakeye M, et al. J Patient Saf Risk Manag. 2023;28:201-207.
Older adult patients and family caregivers face numerous safety challenges when transitioning from the hospital to skilled home health (HH). This article describes how older adults and their family caregivers, HH frontline providers, HH leadership, and HH hospital-based transition coordinators, were engaged to identify best practices to implement the Hospital-to-Home Health Transition Quality (H3TQ) Index. This participatory co-design process identified ways patients, caregivers, and staff differ in how and when to administer the H3TQ Index, confirming the importance of engaging a wide range of stakeholders in design processes.
Lång K, Josefsson V, Larsson A-M, et al. Lancet Oncol. 2023;24:936-944.
Retrospective studies have shown artificial intelligence (AI) to be at least as accurate as radiologists in detecting breast cancer in screening mammograms. This prospective randomized trial similarly demonstrated that AI readings were as accurate as double readings by radiologists, but with a significantly reduced workload.
Winter SG, Sedgwick C, Wallace-Lacey A, et al. Clin Ther. 2023;45:928-934.
The VIONE (Vital, Important, Optional, Not indicated, and Every medication has an indication) tool is used to reduce polypharmacy and potentially inappropriate prescribing. This article provides an overview of VIONE implementation and dashboards used to track VIONE implementation and its impact on prescribing across over 130 Veterans Health Administration medical centers. Since implementation in 2016, VIONE has led to the discontinuation of over 1.6 million medication orders by more than 15,000 providers.
Munn LT, Lynn MR, Knafl GJ, et al. J Res Nurs. 2023;28:354-364.
Nursing team dynamics can influence safety culture and willingness so speak up about errors and safety concerns. This survey of over 650 nurses and nurse managers underscored the importance of leader inclusiveness, safety climate, and psychological safety in cultivating speaking up behaviors among nursing team members.
Ruppel H, Dougherty M, Bonafide CP, et al. BMJ Open Qual. 2023;12:e002342.
Alarm fatigue can lead to desensitization to safety alerts and threaten patient safety. In this survey of 3,986 registered nurses, the majority (83%) reported alarm fatigue and over half (55%) experienced a situation where an alarm went unchecked despite a patient requiring urgent attention. The researchers found that alarm burden was more common among respondents who rated their hospital’s safety as poor or reported poor work environments.
Beauvais B, Dolezel D, Ramamonjiarivelo Z. Healthcare (Basel). 2023;11:2758.
Patient safety improvement efforts involve financial expenditures, which means that hospital leaders must evaluate their return on investment. This study examines the association of several quality-of-care measures and hospital profitability as measured by patient revenue per adjusted discharge. Better patient satisfaction, lower readmission rates, and three of the four Hospital Value-Based Purchasing Program (HVBP) domains were associated with improved financial outcomes.
MohammadiGorji S, Joseph A, Mihandoust S, et al. HERD. 2023;Epub Aug 8.
Well-designed workspaces minimize disruptions and distractions. This review and study describes several important ways to improve the anesthesia workspace in the operating room. Recommendations include demarcating an anesthesia zone with adequate space for equipment and storage and that restricts unnecessary staff travel into and through the zone. Each recommendation includes an illustrative diagram, explains its importance, and offers methods to achieve it.
Lång K, Josefsson V, Larsson A-M, et al. Lancet Oncol. 2023;24:936-944.
Retrospective studies have shown artificial intelligence (AI) to be at least as accurate as radiologists in detecting breast cancer in screening mammograms. This prospective randomized trial similarly demonstrated that AI readings were as accurate as double readings by radiologists, but with a significantly reduced workload.
Porter TH, Peck JA, Bolwell B, et al. BMJ Lead. 2023;7:196-202.
Authentic leadership principles emphasize the influence of positive psychological capacities to foster self-awareness and self-regulated positive behaviors. This qualitative study used podcast transcripts to explore the experiences of senior leadership during the COVID-19 pandemic and the role of authentic leadership principles. The researchers identified several behaviors demonstrating authentic leadership and discuss its influence of psychological safety, particularly during a crisis.
Liu Y, Jun H, Becker A, et al. J Prev Alz Dis. 2023;Epub Oct 24.
Persons with dementia are at increased risk for adverse events compared to those without dementia, highlighting the importance of a timely diagnosis. In this study, researchers estimate approximately 20% of primary care patients aged 65 and older are expected to have a diagnosis of mild cognitive impairment or dementia; however, only 8% have received such a diagnosis. Missed diagnosis prevents patients from receiving appropriate care, including newly FDA-approved medications to slow cognitive decline.
O’Leary KJ, Johnson JK, Williams MV, et al. Ann Intern Med. 2023;Epub Oct 31.
Teamwork is an essential component of ensuring high quality, safe healthcare. This article describes findings from the Redesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study, which evaluated the impact of complementary interventions to redesign unit-based care (unit-based physician teams, nurse-physician co-leadership, interprofessional rounds, performance reports, patient engagement) on interprofessional teamwork and patient outcomes. Findings demonstrate improved teamwork climate scores among nurses (but not physicians), but researchers did not identify a significant impact on patient outcomes.
Winter SG, Sedgwick C, Wallace-Lacey A, et al. Clin Ther. 2023;45:928-934.
The VIONE (Vital, Important, Optional, Not indicated, and Every medication has an indication) tool is used to reduce polypharmacy and potentially inappropriate prescribing. This article provides an overview of VIONE implementation and dashboards used to track VIONE implementation and its impact on prescribing across over 130 Veterans Health Administration medical centers. Since implementation in 2016, VIONE has led to the discontinuation of over 1.6 million medication orders by more than 15,000 providers.
Krogh TB, Mielke-Christensen A, Madsen MD, et al. BMC Med Educ. 2023;23:786.
Medical trainees suffer from "second victim syndrome" (SVS) at rates similar to practicing healthcare professionals but they may not have the same resources to recover. This study of medical students' experiences describes the usual triggers of SVS such as patient harm, but also from negative responses by supervising physicians. Formal instruction and open discussion of SVS can support students' well-being and recovery.
Mudrik-Zohar H, Chowers M, Temkin E, et al. Infect Control Hosp Epidemiol. 2023;44:1562-1568.
Nosocomial infections remain a persistent patient safety issue and can lead to serious patient harm. This article describes one Israeli hospital’s experience using department-level investigations to reduce the incidence of nosocomial bloodstream infections. Study findings demonstrated that department-level investigations coupled with increased staff awareness led to significant reductions in nosocomial bloodstream infections.
Weenink J-W, Tresfon J, van de Voort I, et al. BMC Health Serv Res. 2023;23:1048.
Promoting resilience across and within healthcare organizations is a key component of Safety-II. This qualitative study involving six teams across three hospitals in the Netherlands found that healthcare professionals, managers, and quality advisors hold differing perspectives regarding the right approach to clinical practices and the importance of certain clinical actions. The authors underscore the importance of team reflections to foster resilience and accountability across all levels within healthcare organizations.
Pozzobon LD, Rotter T, Sears K. Healthc Manage Forum. 2023;Epub Oct 13.
Patient and caregiver engagement in patient safety can improve individual outcomes and help identify safety threats. This article highlights the advantages of including patients in patient safety event reporting, including broadening the understanding of harm to include psychological and financial harms, identifying contributing factors to harm, and notes several organizational activities where patients and caregiver involvement can be integrated.
Arbaje AI, Greyson S, Keita Fakeye M, et al. J Patient Saf Risk Manag. 2023;28:201-207.
Older adult patients and family caregivers face numerous safety challenges when transitioning from the hospital to skilled home health (HH). This article describes how older adults and their family caregivers, HH frontline providers, HH leadership, and HH hospital-based transition coordinators, were engaged to identify best practices to implement the Hospital-to-Home Health Transition Quality (H3TQ) Index. This participatory co-design process identified ways patients, caregivers, and staff differ in how and when to administer the H3TQ Index, confirming the importance of engaging a wide range of stakeholders in design processes.
Lim PJH, Chen L, Siow S, et al. Int J Qual Health Care. 2023;35:mzad086.
Surgical safety checklists (SCC) are utilized around the world, but checklist completion at the operating room level remains inconsistent. This review summarizes facilitators and barriers to completion. Resistance or endorsement at the individual surgeon level remains a significant factor in SSC completion. Early inclusion of frontline staff in evaluation and implementation supported increased use.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.
Maternal health care is rapidly emerging as a high-risk service that is vulnerable to communication, equity, and diagnostic challenges. This report examines the role of disparities in care across the maternal care continuum and strategies to drive diagnostic improvement such as care bundles, midwives, and health information technology. This publication is from a series of programs and resultant publications on improving diagnostic excellence.
International Meeting/Conference
American Hospital Association. December 7, 2023. 1:00-2:00 PM (eastern).
Health care organizations require a systems approach to address patient safety challenges and sustain improvements. This session will feature three health care executives who will discuss how to align quality and safety efforts to effectively measure performance, create value, and support transparency.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute Care. November 2, 2023;28(22):1-4.
Intravenous (IV) push medication administration is a primary therapeutic approach where process gaps can result in harm. This article examines existent presence of recognized safe practice education in close to 200 surveyed nursing programs to assess the teaching of standardized practice behaviors at the student level and recommend strategies to embed IV safety into instruction efforts.
Galappatthy P, Mair A, Dhingra-Kumar N et al. Geneva, Switzerland: World Health Organization; 2023. ISBN 9789240058897.
Look-alike, sound-alike (LASA) medicines are known contributors to drug errors. This report discusses how name and label similarities degrade care, and the actions organizations and individual practitioners can take to mitigate the potential of LASA medication errors that cause harm. The authors discuss obstacles and enablers to implementing prevention strategies.
Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication no. 23-0055.
Falls are a frequently reported sentinel event. This Data Spotlight from AHRQ’s Network of Patient Safety Databases (NPSD) highlights the most common interventions in place among patients who experienced a fall such as nonslip wear, bed height and visible risk identification. Data for the analysis includes reports on patient safety concerns submitted from 2009 through 2021.
Special or Theme Issue
Arnal-Velasco, D, ed. Curr Opin Anaesthesiol. 2023;36(6):649-705.
Adoption of new ideas is necessary to create safety in the perioperative environment. This collection of reviews illustrates relationships and tensions between technology, human factors and safety management that create the sociotechnical system within which technology is used to deliver anesthesia. Topics covered include artificial intelligence, decision making and perioperative deterioration.
This Month’s WebM&Ms
WebM&M Cases
Hang Mieu Ha, DO and Kristin Alexis Olson, MD |
A 32-year-old man presented to the hospital with a comminuted midshaft femoral fracture after a bicycle accident. Imaging suggested the fracture was pathologic and an open biopsy specimen was submitted to pathology for intraoperative consultation. However, this procedure was followed by a series of events that increased the likelihood for harm, including the inability to provide a definitive diagnosis at the time of frozen section examination, the subsequent delayed diagnosis, lack of cross coverage for leave among care team members, and poor communication and handoffs.
WebM&M Cases
Scott MacDonald, MD |
This WebM&M describes two cases illustrating several types of Electronic Health Record (EHR) errors, with a common thread of erroneous use of electronic text-generation functionality, such as copy/paste, copy forward, and automatically pulling information from other electronic sources to populate clinical notes. The commentary discusses other EHR-based documentation tools (such as dot phrases), the influence of new documentation guidelines, and the role of artificial intelligence (AI) tools to capture documentation.
WebM&M Cases
Nidhi Patel Jain, PharmD, MBAc and David Dakwa, PharmD, MBA, BCPS, BCSCP |
A 2-year-old girl presented to the emergency department (ED) with joint swelling and rash following an upper respiratory infection. After receiving treatment and being discharged with a diagnosis of allergic urticaria, she returned the following day with worsening symptoms. Suspecting an allergic reaction to amoxicillin, the ED team prepared to administer methylprednisolone. However, the ED intake technician erroneously switched the patient’s height and weight in the electronic health record (EHR), resulting in an excessive dose being ordered and dispensed. An automatic error message was generated due to the substantial difference from previous weights, but this message was overlooked by the ED technician and the data entry error was not detected or corrected. The commentary discusses the importance of verifying medication orders before administration, optimizing alert notifications to minimize the risk of alert fatigue, and the role of root cause analysis to identify factors contributing to medication error
This Month’s Perspectives
Interview
Cheryl B. Jones, PhD, RN, FAAN |
Editor’s note: Cheryl B. Jones is a professor, director of the Hillman Scholars Program, and interim associate dean of the School of Nursing’s PhD program at the University of North Carolina at Chapel Hill. We spoke to her about workplace violence trends in healthcare settings and how we can create a safer work environment for healthcare staff.
Perspectives on Safety
Cheryl B. Jones, PhD, RN, FAAN; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD |
This piece focuses on workplace violence trends in healthcare settings and strategies for creating a safer healthcare environment.
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