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July 24, 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
Kepner S, Bennett A, Jones RM. Patient Safety. 2024;6.
Preventing healthcare-associated infections continue to be a challenge in long-term care settings. Based on reports submitted by long-term care facilities to the Pennsylvania Patient Safety Reporting System (PA-PSRS), infection rates increased for skin and soft tissue, urinary tract, and respiratory tract infections. This continues the trend seen in the 2022 report.
McGrane N, Behan L, Keyes LM. Health Hum Rights. 2024;26:115-128.
Many regulatory authorities require notification of adverse events involving vulnerable individuals, such as those in care facilities. In this study, almost 200 statutory notifications from residential care facilities (RCF; e.g., nursing homes, assisted living) were analyzed to ensure residents' human rights (fairness, respect, equality, dignity, and autonomy) were upheld during adverse events. In the majority of adverse events and their management, residents' human rights were upheld.
Sloane J, Singh H, Upadhyay DK, et al. Jt Comm J Qual Patient Saf. 2024;Epub May 31.
Improving the diagnostic process requires multipronged and multidisciplinary approaches to achieve lasting improvements. This qualitative study involving 25 individuals associated with the Safer Dx Learning Lab identified several program successes, such as improved reporting workflow and safety culture fostering psychological safety. Participants also highlighted lessons learned, including leadership buy-in and the need for protected time for clinicians to participate in case review and continuous learning.
Scannell GA, Bevan DJ, Cowan A, et al. J Am Med Dir Assoc. 2024;25:105006.
Transitions of care between health care settings and home can introduce opportunities for adverse events, particularly among vulnerable patients. This article describes the pilot implementation of the Geriatric High-Risk Evaluation and Liaison Program – Transitional Care (GHELP-TC) which aims to improve care transitions between acute care to skilled nursing and skilled nursing to home for older veterans. This pilot evaluation identified 79 medication errors and 80 appointment errors among 90 enrolled veterans. A planned expanded implementation will include registered nurses (RNs) to improve communication and accountability.
McGrane N, Behan L, Keyes LM. Health Hum Rights. 2024;26:115-128.
Many regulatory authorities require notification of adverse events involving vulnerable individuals, such as those in care facilities. In this study, almost 200 statutory notifications from residential care facilities (RCF; e.g., nursing homes, assisted living) were analyzed to ensure residents' human rights (fairness, respect, equality, dignity, and autonomy) were upheld during adverse events. In the majority of adverse events and their management, residents' human rights were upheld.
Chanelière M, Buchet-Poyau K, Keriel-Gascou M, et al. BMC Prim Care. 2024;25:244.
Voluntary incident reporting remains low despite its demonstrated importance in improving patient safety. This randomized controlled trial tested the impact of a multidisciplinary effort to increase event reporting in primary care settings. The intervention included e-learning training modules, identification of a risk management advisor, and multidisciplinary meetings focused on patient safety incidents at each facility. Only 7 of the 17 facilities fully implemented the program, and there were no improvements in reporting rates in intervention or control facilities.
Amici LD, van Pelt M, Mylott L, et al. Anesth Analg. 2024;Epub Jun 13.
Computerized clinical decision support (CDS) helps prevent medication errors throughout the medication process. This study evaluated self-reported medication errors in the operating room to establish if CDS could have prevented them. Eighty medication errors were reported with 95% determined to be potentially preventable with CDS. All wrong medication, wrong dose, and documentation errors were rated as potentially preventable.
Wasserman RL, Edrees HH, Amato MG, et al. BMJ Qual Saf. 2024;Epub Jul 9.
Adverse drug events (ADEs) remain a persistent patient safety challenge. This retrospective analysis of 3,323 patients treated in outpatient settings in 2018 found that 5% experienced an ADE. Most ADEs involved cardiovascular, central nervous system, or anti-infective medications. The researchers concluded that 22% of these ADEs were likely preventable through strategies such as improved education, training, communication, and monitoring or the use of clinical decision support tools or alerts.
Aunger JA, Abrams R, Mannion R, et al. BMJ Open Qual. 2024;13:e002830.
Disruptive and unprofessional behavior jeopardizes patient safety and the overall quality of care. This paper underlines the importance of mapping the individual drivers of unprofessional behavior to strategies that address them. The authors’ program theory (PT) maps drivers and strategies to serve as a basis for developing evidence-based interventions to reduce unprofessional behavior.
Kruse JA, Podojil-Kostecki P, Smith B. AANA J. 2024;92:173-180.
Many healthcare staff who are involved in an adverse event may experience negative physical and psychological aftereffects. This study of certified registered nurse anesthetists (CRNA) in Michigan found 20% of respondents experienced psychological distress and 16% experienced physical distress. Peer support was the most important type of support following an event. Institutional support was inadequate.
Kepner S, Bennett A, Jones RM. Patient Safety. 2024;6.
Preventing healthcare-associated infections continue to be a challenge in long-term care settings. Based on reports submitted by long-term care facilities to the Pennsylvania Patient Safety Reporting System (PA-PSRS), infection rates increased for skin and soft tissue, urinary tract, and respiratory tract infections. This continues the trend seen in the 2022 report.
Georgantes ER, Gunturkun F, McGreevy TJ, et al. J Nurs Scholarsh. 2024;Epub May 21.
Nurse sensitive indicators (NSI) can help organizations identify areas for improvement. Rates of three nurse sensitive indicators - falls, healthcare associated pressure injuries, and healthcare associated infections - in one hospital were analyzed to identify if disparities exist and to create a model for identifying patients at risk. Patients with at least one NSI were more likely to have been admitted emergently, admitted to the ICU, and have longer ICU and hospital stays than patients with no NSI. Race/ethnicity was not associated with the risk of experiencing an NSI.
Sloane J, Singh H, Upadhyay DK, et al. Jt Comm J Qual Patient Saf. 2024;Epub May 31.
Improving the diagnostic process requires multipronged and multidisciplinary approaches to achieve lasting improvements. This qualitative study involving 25 individuals associated with the Safer Dx Learning Lab identified several program successes, such as improved reporting workflow and safety culture fostering psychological safety. Participants also highlighted lessons learned, including leadership buy-in and the need for protected time for clinicians to participate in case review and continuous learning.
Leon C, Hogan H, Jani YH. Int J Qual Health Care. 2024;36:mzae057.
Incident reports provide valuable learning opportunities at individual, team, and organizational levels. This study used incident reports involving anticoagulant medication errors to demonstrate the effectiveness of Systems Engineering Initiative for Patient Safety (SEIPS) and healthcare resilience as an alternative investigative approach. Report descriptions included all the SEIPS components and resilience capacities (e.g., preparedness, adaptation), indicating this method can be used to complement traditional investigative methods.
Pellegrino A, Brook K. J Patient Saf. 2024;Epub Jun 28.
Patient falls are a never event; every fall should be reported and thoroughly investigated. This commentary describes the challenges of using national falls databases to learn from falls occurring in the periprocedural environment. The authors recommend a national database specific to periprocedural falls and offer suggestions on prevention of falls in and around the operating room.
Commentary
Johnson V. N Engl J Med. 2024;391:6-7.
Resident physicians are vulnerable to psychological harm when they have made a mistake. This commentary shares one resident’s experiences with error. The author discusses the importance of finding support and sharing experiences with colleagues who have been challenged by errors and managing their impact to assist in the return of their confidence to practice.
No results.
No results.
Book/Report
London, England: National Voices; 2024.
The discussion of diagnostic safety has expanded to include an effort to realize excellence. This report explores the diagnostic process in the United Kingdom to reveal contributing factors to inequalities, biases, and delays that result in misdiagnosis and limited care. The authors highlight successes that support patient-centered care, including multidisciplinary teams, improved communication, and access to specialists.
Newspaper/Magazine Article
Mate KS, Clark J, Salvon-Harman J. Harvard Business Review. July 12, 2024;
While a focus on the systems approach is a long-standing element of patient safety improvement, organizations are still challenged to fully adopt this concept. This commentary describes elements of a care operating system designed to support patient safety and worker well-being through the design of processes that generate excellence, transparency, and reliability.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Scott Zakaluzny, MD, FACS |
A 67-year-old man with severe low back pain was admitted to the hospital for anterior lumbar interbody fusion (ALIF) with bone autograft from the iliac crest. The surgical team had difficulty controlling bleeding and the patient left the operating room (OR) with the bone graft donor site open and oozing blood. In the postanesthesia care unit (PACU), the nurse called the attending physician three times to report hypotension and ongoing bleeding. Each time, the surgeon ordered hetastarch for volume expansion. Over the next 14 hours, the patient’s blood pressure remained at or below 90/60 with continued complaints of back and pelvic pain. The next morning, the patient was unresponsive and in severe hypovolemic shock. Electrocardiography confirmed a non-ST segment elevation myocardial infarction (NSTEMI). The patient was transferred to an intensive care unit and resuscitative efforts were initiated, but the patient expired from multiorgan failure resulting from hypovolemic shock. The commentary discusses appropriate management of ongoing intraoperative and postoperative bleeding and how a culture of safety can enable care team members to voice concerns about patient safety.
WebM&M Cases
Christian Bohringer, MB BS and Gustavo Chavez, MD |
A 36-year-old woman with class 2 obesity underwent a difficult laparoscopic hysterectomy, performed in the lithotomy position with a steep head down (Trendelenburg) position. Intermittent pneumatic compression devices were placed on both calves to prevent venous thrombosis (DVT), but on awakening from general anesthesia, the patient complained of severe pain in the right leg. The gynecologist made a presumptive diagnosis of DVT and put her on subcutaneous dalteparin at therapeutic dosing and acetaminophen and oral morphine for pain relief. The patient continued to complain of severe pain and paresthesias in her right calf and doppler ultrasound scan was negative for DVT. The next day the orthopedic on-call team was consulted and diagnosed compartment syndrome of the right leg. The patient required fasciectomy of the right leg and excision of necrotic muscle tissue, with a prolonged hospital stay. The commentary discusses how patient positioning during surgery can increase the risk for surgical complications, the role of interdisciplinary teamwork to achieve optimal positioning, and the importance of early identification of compartment syndrome to prevent permanent injury.
This Month’s Perspectives
Interview
Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD |
Amy Helwig, MD, MS, FAAFP, is the Chief Quality Officer at Commonwealth Care Alliance. We spoke to her about the health plan’s role in monitoring and improving patient safety.
Perspectives on Safety
Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD |
This piece explores the health plan’s role in improving patient safety, including how health plans are monitoring patient safety and health plan-level initiatives to improve patient safety.
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