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March 13, 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

Hooven K, Altmiller G. AORN J. 2024;119:152-160.
Fear of retaliation by leaders or colleagues can prevent staff from reporting adverse events, unsafe conditions, or near misses. This article presents strategies to improve just culture in the perioperative environment, which is prone to hierarchical structure. Strategies include creating an accessible reporting system, implementation of a "good catch" program, and leadership support for staff who submit reports.
Holmes L, Enwere M, Mason R, et al. Healthcare (Basel). 2024;12:477.
Structural racism in the healthcare system and beyond contributes to disproportionally high mortality for Black children. In this study, researchers compared mortality rates of Black and white infants using the International Classification of Diseases (ICD) subclass Misadventures to Patients During Surgical and Medical Care, where the authors defined misadventures as "the fatal medical errors that occur among healthcare providers, such as the slipping of a scalpel or administration of an incorrect dosage or drug." During the study period of 1968 - 2015, results show Black infants were at significantly higher risk of dying from medical misadventure than were white infants.
Marcin JP, Lieng MK, Mouzoon J, et al. JAMA Netw Open. 2024;7:e240275.
Medication errors among children remain a patient safety challenge. This cluster randomized trial evaluated medication errors among critically ill children presenting to the Emergency Department (ED) and randomized to receive either video telemedicine or telephone consultations with pediatric critical care physicians. A physician-related medication error occurred in 12.5% of participants overall, with no statistically significant differences between the video telemedicine or telephone consultation groups.
Hassan B, Tawfik M-M, Schiff E, et al. Jt Comm J Qual Patient Saf. 2023;Epub Nov 22.
In situ simulation can identify latent safety threats before they reach a patient. In this study, 20 multidisciplinary teams participated in in situ simulations of a tracheostomy emergency in an adult patient. Only ten of the teams were able to reestablish the airway within the allotted five minutes, and 12 types of human errors and 15 types of latent safety threats were identified.
DeGennaro AP, Gonzalez N, Peterson SM, et al. Diagnosis (Berl). 2024;11:97-101.
Diagnostic uncertainty is common, particularly in the emergency department (ED) or urgent care where patients are typically unknown to the provider, and the goal of care is to provide a patient with a plan, such as follow-up with primary care provider. In this study, patients and care partners describe their experiences with diagnostic uncertainty in the ED or urgent care. 73% reported poor communication with the most common subtheme being poor explanation.
Kendal S, Louch G, Walker L, et al. J Psychiatr Ment Health Nurs. 2024;Epub Jan 27.
Patient safety issues in mental health care settings are understudied. This qualitative study evaluated the implementation of ‘WardSonar,’ a tool designed to digitally monitor and communicate safety perceptions from adult acute mental health patients to staff. Feedback from patients and staff was generally positive, although some staff reported that they did not need the tool to understand patients’ safety concerns.
Ojute F, Gonzales PA, Berler M, et al. J Surg Educ. 2024;Epub Feb 21.
Psychological safety among care providers, including residents, can foster patient safety and promote clinician wellbeing. This mixed-methods study explored general surgery residents’ perceptions of psychological safety support in the workplace and the relationship between psychological safety and resident wellbeing. Findings underscore the importance of supportive mentorship as well as a culture that embraces and destigmatizes asking for help.
Holmes L, Enwere M, Mason R, et al. Healthcare (Basel). 2024;12:477.
Structural racism in the healthcare system and beyond contributes to disproportionally high mortality for Black children. In this study, researchers compared mortality rates of Black and white infants using the International Classification of Diseases (ICD) subclass Misadventures to Patients During Surgical and Medical Care, where the authors defined misadventures as "the fatal medical errors that occur among healthcare providers, such as the slipping of a scalpel or administration of an incorrect dosage or drug." During the study period of 1968 - 2015, results show Black infants were at significantly higher risk of dying from medical misadventure than were white infants.
Woodier N, Burnett C, Sampson P, et al. J Patient Saf Risk Manag. 2023;29:47-53.
Near-miss patient safety events offer unique learning opportunities. This qualitative study explored patient safety learning from near-miss events in the National Health Service. Participants noted the limited processes available for reporting near-miss events and insufficient support for reporting near-miss events, which can hinder opportunities for learning.
Obadan-Udoh E, Howard R, Valmadrid LC, et al. J Patient Saf. 2024;Epub Feb 12.
Patient safety issues in dentistry are receiving increasing attention. Based on 67 individual patient interviews, researchers in this study explored patient perspectives about the impact of dental diagnostic errors. Participants identified several categories of contributing factors, including clinician issues (e.g., poor communication), patient issues (e.g., lack of self-advocacy), and system factors (e.g., insurance challenges, workload).
Westbrook JI, Li L, Woods AL, et al. Stud Health Technol Inform. 2024;310:329-333.
Medication administration errors remain a common cause of preventable harm. This randomized trial investigated the impact of an electronic medication system on medication administration errors among pediatric patients at one referral hospital in Sydney, Australia. After implementation, researchers found no significant impact on medication errors with potential for serious harm or errors involving high-risk drugs.
Marcin JP, Lieng MK, Mouzoon J, et al. JAMA Netw Open. 2024;7:e240275.
Medication errors among children remain a patient safety challenge. This cluster randomized trial evaluated medication errors among critically ill children presenting to the Emergency Department (ED) and randomized to receive either video telemedicine or telephone consultations with pediatric critical care physicians. A physician-related medication error occurred in 12.5% of participants overall, with no statistically significant differences between the video telemedicine or telephone consultation groups.
Facey M, Baxter NN, Hammond Mobilio M, et al. Sociol Health Illn. 2024;Epub Feb 1.
Surgical safety checklists (SSC) have been shown to improve patient safety, but several studies have exposed they are not always completed as intended. This ethnographic study concludes, thorough interviews, surveys, and observations, that the SCC tends to be completed as a perfunctory task, not to improve patient safety.
Hooven K, Altmiller G. AORN J. 2024;119:152-160.
Fear of retaliation by leaders or colleagues can prevent staff from reporting adverse events, unsafe conditions, or near misses. This article presents strategies to improve just culture in the perioperative environment, which is prone to hierarchical structure. Strategies include creating an accessible reporting system, implementation of a "good catch" program, and leadership support for staff who submit reports.
Hunt DF. BMJ Lead. 2024;Epub Jan 17.
Psychological safety is critical for all staff in health systems, including leadership. This article encourages leaders to acknowledge their limitations, as this creates a culture of trust and enables innovation by including a wide range of stakeholders. The authors also acknowledge challenges associated with displaying vulnerability and strategies to overcome them.
Whitaker DK, Lomas JP. Anaesthesia. 2024;79:119-122.
Simplifying complex processes is a strategy to engineer safety into health care. This article discusses the use of prefilled syringes as a tactic to reduce the potential for error in intravenous medication administration. The author argues for broader acceptance of this strategy across the practice of anesthesiology.
Goldberg CB, Adams L, Blumenthal D, et al. NEJM AI. 2024;1.
Artificial intelligence (AI) is increasingly being used and studied in healthcare. This perspective shares insights from the RAISE (Responsible AI for Social and Ethical Healthcare) conference, highlighting that AI in healthcare needs to enhance patient care, support healthcare professionals, and be accessible and safe for all.
Um IS, Clough A, Tan ECK. Res Social Adm Pharm. 2024;20:1-9.
Pharmacy dispensing errors continue to be a source of preventable harm. Based on a systematic review of 62 studies, these authors report a global pooled prevalence of medication dispensing errors of 1.6% (range, 0-33%) across community, hospital, and other pharmacy settings.
Im DS, Tamarelli CM, Shen MR. J Gen Intern Med. 2024;39:283-300.
When a physician's unprofessional behavior is reported by patients, families, or staff, an appropriate investigation must be conducted. While the investigations are critical for ensuring patient safety, physicians experience negative emotional and mental impacts, as well as changes to their clinical practice (e.g., defensive medicine). This review summarizes studies on physicians' experiences during and after investigations and mitigation strategies.

Healthcare Quality Institute. March 28, 2024, 2:00 -3:00 PM (eastern).

Central line associated bloodstream infections (CLABSIs) are a long-standing, preventable threat to patient safety. This webinar will highlight one health system’s successful multidimensional approach to eliminating CLABSIs in their organization for three years.

Agency for Healthcare Research and Quality. Fed Register. Mar 6, 2024;89(45);15992.

A standard system for voluntary reporting to patient safety organizations improves measurement of errors in the hospital environment. This announcement calls for the review of Common Formats for Surveillance – Hospital Version 1.0, and supplies links to the draft formats for public comment. The process for submitting comments is open until April 5, 2024.

Booth G, ed.  Anamnesis. MedPage Today. March 1, 2024.

The dismissal of patient health concerns by providers degrades diagnosis, treatment, and trust. This collection of three podcasts illustrates gaslighting as experienced by clinicians in the diagnosis of brain tumors, individual denial of illness, and delayed recognition of long Covid due to weight bias.

This Month’s WebM&Ms

WebM&M Cases
Christian Bohringer, MBBS and Linda Vo, MD |
A 47-year-old obese man with hypertension fell and suffered a cervical spine (C5/C6) fracture. He was scheduled for urgent anterior cervical decompression and fusion and was transferred to the operating room (OR) where general anesthesia was induced. During the procedure, his expired tidal volume decreased from 560 ml to about 330 ml. He was manually ventilated through the endotracheal tube, which proved very difficult. An urgent chest X-ray did not reveal any pneumothorax. The Black Belt cervical retractor was released by the surgeon resulting in complete resolution of the airway obstruction. The commentary highlights the importance of vigilant monitoring and good communication to identify and respond to life-threatening events and describes approaches to improve crisis management during anesthesia events.
WebM&M Cases
Timothy Do, BS and Fiona J Scott, MD, MPH, MS, MHI |
A 32-year-old woman was admitted to the hospital for endoscopic retrograde cholangiopancreatography (ERCP) under monitored anesthesia care (MAC). As the endoscope was advanced into the stomach, the patient vomited. She was immediately turned supine but copious vomitus obstructed the suction catheter. The patient started to decompensate with decreasing oxygen saturation. The anesthesia team attempted to secure the airway by endotracheal intubation but was unable to place a tube due to poor view and vomitus. The patient went into cardiac arrest and ultimately passed away. The commentary discusses safety considerations for ERCP under MAC, weighing the risks and benefits of MAC versus general anesthesia, and airway management during emergencies.

This Month’s Perspectives

Stephen Hines headshot
Interview
Monika Haugstetter, MHA, MSN, RN, CPHQ; Stephen Hines, PhD |
Monika Haugstetter, MHA, MSN, RN, CPHQ, is a Health Science Administrator with AHRQ, leading AHRQ’s TeamSTEPPS® initiative. Stephen Hines, PhD, is a Senior Research Scientist at the Arbor Research Collaborative for Health. While at Abt Associates, he co-led the TeamSTEPPS 3.0 revisions in collaboration with AHRQ. We spoke with Monika and Stephen about the newly released TeamSTEPPS 3.0 curriculum.
Perspective
Monika Haugstetter, MHA, MSN, RN, CPHQ; Stephen Hines, PhD; Zoe Sousane, BS; Sarah Mossburg, RN, PhD |
This piece discusses the impact of AHRQ’s TeamSTEPPS training curriculum on patient safety and highlights updates made to the curriculum in 2023 with the launch of TeamSTEPPS 3.0.
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