Email Updates
September 27, 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
Cornell EG, Harris E, McCune E, et al. Diagnosis (Berl). 2023;Epub Aug 21.
Structured handoffs can improve the quality of patient information passed from one care team to another. This article describes intensivists' perspectives on a potential handoff tool (ICU-PAUSE) for handoff from the intensive care unit (ICU) to medical ward. They described the usefulness of a structured clinical note, especially regarding pending tests and the status of high-risk medications. Several barriers were also discussed, such as the frequent training required for residents who rotate in and out of the ICU and potential duplication of the daily chart note.
Gilmartin HM, Saint S, Ratz D, et al. Infect Control Hosp Epidemiol. 2023;Epub Sep 13.
Burnout has been reported across numerous healthcare settings and disciplines during the COVID-19 pandemic. Among US hospital infection preventionists surveyed in this study, nearly half reported feeling burnt out, but strong leadership support was associated with lower rates of burnout. Leadership support was also associated with psychological safety and a stronger safety climate.
Kotagal M, Falcone RA, Daugherty M, et al. J Trauma Acute Care Surg. 2023;95:426-431.
Simulation can be used to identify latent safety threats (LSTs) when implementing new workflows or care locations. In this study, simulation scenarios were used to identify LSTs associated with the opening of a new emergency department and critical care area. The 118 identified threats involved equipment, structural or layout issues, resource concerns, and knowledge gaps. Failure mode and effects analysis informed an action plan to mitigate these threats.
Matern LH, Gardner R, Rudolph JW, et al. J Clin Anesth. 2023;90:111235.
Effective team communication is essential during crisis management. In this study, 60 anesthesiologists participating in a simulated perioperative anaphylaxis crisis scenario identified common clinical factors prompting crisis acknowledgement.
Moore QT, Bruno MA. Radiol Technol. 2023;94(6):409-418.
Fostering a culture of safety is a key objective across all clinical areas, including radiology. This secondary analysis of survey data found that radiologists working night shifts and shifts exceeding 12 hours have poor perceptions of teamwork and of leadership actions concerning radiation safety.
Gil-Hernández E, Carrillo I, Tumelty M-E, et al. Med Sci Law. 2023;Epub Jun 27.
Patient safety is a global health concern. For this study, representatives from 27 countries reported on rules, laws, and policies in their country related to adverse events and medical errors. As expected, laws varied widely between countries regarding issues such as apology laws, patient compensation schemes, and legal and emotional support for clinicians involved in adverse events.
DeCoster MM, Spiller HA, Badeti J, et al. Pediatrics. 2023;Epub Sep 18.
Data from the National Poison Data System is useful for describing characteristics and trends of out-of-hospital medication errors. This retrospective study describes trends in therapeutic errors involving attention deficit/hyperactivity disorder (ADHD) medications as reported to poison control centers in the United States. From 2000 to 2021, errors increased by 300%, with more than half classified as "inadvertently took or was given medication twice." Although no deaths were reported and less than 5% resulted in moderate or major medical outcomes, increased patient and caregiver education and child-resistant medication containers are needed.
Li E, Lounsbury O, Clarke J, et al. BMC Med Inform Decis Mak. 2023;23:158.
Shortfalls in electronic health record (EHR) interoperability can threaten patient safety. Chief clinical information officers (CCIOs) participating in semi-structured interviews highlighted the ways in which limited EHR interoperability adversely impacts patient health and safety by hindering care coordination and creating inefficient care processes. Participants noted that solutions are necessary at both the technical (e.g., user-centered design) and policy levels.
Cornell EG, Harris E, McCune E, et al. Diagnosis (Berl). 2023;Epub Aug 21.
Structured handoffs can improve the quality of patient information passed from one care team to another. This article describes intensivists' perspectives on a potential handoff tool (ICU-PAUSE) for handoff from the intensive care unit (ICU) to medical ward. They described the usefulness of a structured clinical note, especially regarding pending tests and the status of high-risk medications. Several barriers were also discussed, such as the frequent training required for residents who rotate in and out of the ICU and potential duplication of the daily chart note.
El Boghdady M, Ewalds-Kvist BM. Langenbecks Arch Surg. 2023;408:349.
Disruptive behavior in the healthcare setting can result in neglect of patient care, decreased teamwork, and poor safety culture. This study from the UK found that 22% of surgeons were at risk of displaying disruptive behavior in the workplace and that being bullied during surgical training predicted hostility. These results reinforce the need for strong safety culture and a supportive learning environment for trainees.
Georgiou A, Li J, Thomas J, et al. Public Health Res Pract. 2023;33:e3332324.
Several systemic factors may hinder communication of test results to patients and clinicians. This article describes a research project in Australia, "Delivering safe and effective test result communication, management and follow-up." Along with previously identified test result communication challenges such as workflow and technology, this paper highlights the need for national thresholds for critical laboratory results.
Gilmartin HM, Saint S, Ratz D, et al. Infect Control Hosp Epidemiol. 2023;Epub Sep 13.
Burnout has been reported across numerous healthcare settings and disciplines during the COVID-19 pandemic. Among US hospital infection preventionists surveyed in this study, nearly half reported feeling burnt out, but strong leadership support was associated with lower rates of burnout. Leadership support was also associated with psychological safety and a stronger safety climate.
Atallah F, Gomes C, Minkoff H. Obstet Gynecol. 2023;142:727-732.
Researchers describe two types of decision making in medicine - fast (intuitive) and slow (analytical). While both types are subject to bias, this paper describes how cognitive biases in fast thinking, such as anchoring or framing, as well as racial or moral bias, can result in obstetrical misdiagnosis. Ten steps to mitigate these cognitive biases are laid out.
Kotagal M, Falcone RA, Daugherty M, et al. J Trauma Acute Care Surg. 2023;95:426-431.
Simulation can be used to identify latent safety threats (LSTs) when implementing new workflows or care locations. In this study, simulation scenarios were used to identify LSTs associated with the opening of a new emergency department and critical care area. The 118 identified threats involved equipment, structural or layout issues, resource concerns, and knowledge gaps. Failure mode and effects analysis informed an action plan to mitigate these threats.
Commentary
Kirkup B, Titcombe J. BMJ. 2023;382:1972.
The latent nature of failure in health care is enabled by organizational inability or unwillingness to listen and respond to the concerns of patients, families, and clinicians. This commentary discusses a rare criminal event in the British National Health System (NHS) and the factors that allowed continued criminal activity to occur over time.
O’Mahony D, Cherubini A, Guiteras AR, et al. Eur Geriatr Med. 2023;14:625-632.
STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert to Right Treatment) criteria are used to identify potentially inappropriate prescribing in older adults. This article describes the consensus process to update and validate the third version of the STOPP/START criteria using evidence from a systematic review and input from a panel with expertise in geriatric pharmacology. The consensus process resulted in additional STOPP criteria (133 versus 80 in version 2) and START criteria (57 versus 34 in version 2). The additional criteria in version 3 can help clinicians detect and prevent adverse drug-drug and drug-disease interactions.
Jones A, Neal A, Bailey S, et al. BMJ Lead. 2023;Epub Sep 10.
The well-being of healthcare workers is essential to the delivery of high quality, safe care. This article proposes a definition of “avoidable employee harm” (e.g., retaliation for speaking up about safety concerns) and describes how prioritizing organizational safety culture can increase both employee and patient safety.
Paterson C, Mckie A, Turner M, et al. J Adv Nurs. 2023;Epub Sep 7.
Effective implementation of the WHO Surgical Safety Checklist remains challenging. This qualitative synthesis of 34 studies identified several factors that influence uptake and compliance with the Surgical Safety Checklist, including effective leadership and use of audit and feedback.
Eriksen AA, Fegran L, Fredwall TE, et al. J Clin Nurs. 2023;32:5816-5835.
Patient and family complaints often highlight concerns missed by standard organization incident reporting. This metasynthesis identified four overarching themes: (1) problems with access to health care services; (2) failure to acquire information about diagnosis, treatment, and the expected patient role; (3) experiencing inappropriate care and bad treatment; (4) problems with trusting health care service providers. The breadth of settings, disciplines, and study populations suggests patient complaints can be a useful tool for improving physical and psychological safety for patients.
Meidert U, Dönnges G, Bucher T, et al. Int J Environ Res Public Health. 2023;20:6569.
Biases among healthcare professionals can lead to inequitable care and poor patient outcomes. Based on 81 included studies, the authors of this scoping review concluded that racial bias among physicians and nurses in the United States is well-documented, but noted that research on biases among other health professionals or in other countries is lacking.
United States Meeting/Conference
Medstar Health. Lyon Village Community House, Arlington, VA, October 19 - 20, 2023.
Human factors strategies are a core approach to mitigating the impact of human error in medicine. This workshop will provide a safety science context to the application of human factors engineering to health care. The complementary approaches will be infused with discussions on event review and proactive safety improvement efforts.
Organizational Policy/Guidelines
Irving, TX: American College of Emergency Physicians; 2023.
Error disclosure is difficult yet important for patient and clinician psychological healing. This statement provides guidance to address barriers to emergency physician disclosure of errors that took place in the emergency room. Recommendations for improvement include the development of organizational policies that support error reporting, disclosure procedures, and disclosure communication training.
Yurkiewicz I. New York, NY: WW Norton & Company, Inc; 2023. ISBN: 9780393881196.
Disjointed health care processes contribute to missed test results, incomplete communication, and care omissions that harm patients. This book shares a personal account of how broken care processes serve as a core deterrent in one clinician’s ability to provide the safest care possible.
Newspaper/Magazine Article
Banks MA. Specialty Pharmacy Continuum. September 15, 2023.
Radiofrequency identification (RFID) devices are being used to improve processes in the operating room and prevent errors. This article examines the use of RFID tracking to build reliability into operating room anesthesia medication refiling process. The experience at one hospital found that the RFID process reduced errors, while increasing the task completion time.
Amin D, Cosby K. Rockville, MD: Agency for Healthcare Research and Quality; September 2023. Publication No. 23-0040-6-EF.
Psychological safety to report errors stems from a robust safety culture. This issue brief examines how these two concepts intersect to enhance the self-reporting of diagnostic errors to facilitate organizational learning from mistakes.
This Month’s WebM&Ms
WebM&M Cases
Hana Camarillo, PharmD, BCACP, CDCES |
A 14-year-old girl was admitted to the hospital with a new diagnosis of type 1 diabetes mellitus without ketoacidosis. Before discharge, medications intended for home use were delivered to the patient’s bedside, but the resident physician noticed a discrepancy. An insulin pen and pen needles had been ordered, but an insulin vial and extra insulin syringes were delivered. Neither the patient nor the parents had received education on how to draw up and administer insulin using a vial and syringe. The pharmacy staff reported that the insulin pen was out of stock, so the insulin vial was substituted because it contained the same active ingredient. The insulin product switch was declined, and another pharmacy was contacted to provide the insulin pen, which was delivered to the patient’s bedside the following day. The commentary summarizes the patient safety risks associated with drug shortages, drug interoperability standards, and the importance of clear communication between members of the care team if alternative therapies need to be considered
WebM&M Cases
Commentary by Alyssa Bellini, MD and Edgardo S Salcedo, MD, FACS |
This case highlights two “never events” involving the same patient. A first-year orthopedic surgery resident was consulted to aspirate fluid from the left ankle of a patient in the intensive care unit. The resident, accompanied by a second resident, approached the wrong patient and inserted the needle into the patient’s right ankle. At this point, a third resident entered the room and stated that it was the incorrect patient. The commentary highlights the importance of a proper time out and approaches to improve communication among all members of the care team.
WebM&M Cases
Liliya Klimkiv, MD, Garth Utter, MD, MSc, and David K. Barnes, MD |
This case describes an older adult patient with generalized abdominal pain who was eventually diagnosed with inoperable bowel necrosis. Although she appeared well and had stable vital signs, triage was delayed due to emergency department (ED) crowding, which is usually a result of hospital crowding. She was under-triaged and waited three hours before any diagnostic studies or interventions commenced. Once she was placed on a hallway gurney laboratory and imaging studies proceeded hastily. Catastrophic bowel necrosis was eventually identified, yet she was not moved to a standard ED treatment bed for another 25 minutes. Despite aggressive resuscitation, the surgeon determined that operative intervention was futile, and the patient died a short time later. The commentary highlights how hospital crowding and ED boarding can lead to delayed triage and inefficient ED throughput, which compromises patient safety and summarizes approaches to improving ED triage and throughput.
This Month’s Perspectives
Interview
Kathleen Sanford DBA, RN, FAAN, FACHE; Sue Schuelke PhD, RN-BC, CNE, CCRN-K; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD |
Editor’s note: Kathleen Sanford is the chief nursing officer and an executive vice president at CommonSpirit. Sue Schuelke is an assistant professor at the College of Nursing–Lincoln Division, University of Nebraska Medical Center. They have pioneered and tested a new model of nursing care that utilizes technology to add experienced expert nurses to care teams, called Virtual Nursing.
Perspectives on Safety
Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD |
This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.
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