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January 22, 2025 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

Abdo A, Gallay L, Vallecillo T, et al. Sci Rep. 2024;14(1):32022.
Pharmacist-led medication reconciliation is resource intensive; targeting patients most at risk for medication errors can make the best use of this limited resource. In this study, a machine learning (ML) tool was developed to identify hospitalized patients at risk of medication errors. As standard practice in the study hospital, a pharmacist selected a small random sample of patients for medication reconciliation using an existing tool, with approximately 20% having at least one medication error. Using the ML tool, 45% of identified patients had at least one medication error, outperforming the existing tool.
Bradford A, Tran A, Ali KJ, et al. J Gen Intern Med. . 2024;Epub Oct 22.
AHRQ’s Measure Dx: A Resource to Identify, Analyze, and Learn from Diagnostic Safety Events supports organizational efforts to reduce diagnostic errors. This article describes the efforts of 11 healthcare organizations' implementation and six-month sustainment of Measure Dx. Each of the four case-finding strategies was used, 703 cases were reviewed, and 32% of cases had at least one diagnostic missed opportunity.
Wesevich A, Langan E, Fridman I, et al. JAMA Netw Open. 2024;7(12):e2450172.
Bias and the use of stigmatizing language can compromise patient care. This study, conducted with medical students and residents at two academic medical centers, examined the impact of biased versus neutral language on clinical information recall and attitudes towards patients during simulated handoffs. Findings indicate that biased language (particularly blame-based bias) led to less accurate information recall and more negative attitudes towards patients. The authors conclude that using standardized handoffs can help mitigate racial bias and improve the delivery of safe, equitable care.
Scheurer D, Coulter A, Harper K, et al. NEJM Catalyst. 2024;6(1):CAT.24.0225.
Employee engagement, safety culture, and patient experience are positively associated and typically require ongoing department support and leadership. This article describes development of a system-wide coaching program for department leaders to improve survey scores in one or more of the targeted areas. Organization-wide survey scores improved 12 months after the coaching program was launched.
Abdo A, Gallay L, Vallecillo T, et al. Sci Rep. 2024;14(1):32022.
Pharmacist-led medication reconciliation is resource intensive; targeting patients most at risk for medication errors can make the best use of this limited resource. In this study, a machine learning (ML) tool was developed to identify hospitalized patients at risk of medication errors. As standard practice in the study hospital, a pharmacist selected a small random sample of patients for medication reconciliation using an existing tool, with approximately 20% having at least one medication error. Using the ML tool, 45% of identified patients had at least one medication error, outperforming the existing tool.
Zimolzak AJ, Khan SP, Singh H, et al. J Am Med Inform Assoc. 2025;32(1):227-229.
Missed and delayed diagnosis of cancer delays essential, time-sensitive treatment and can lead to negative patient outcomes. This study examined the use of a digital quality measure (dQM) of emergency presentation of lung cancer (defined as an emergency encounter followed by a new lung cancer diagnosis within 30 days) in a large dataset covering 184 million U.S. patients. The findings indicate the overall emergency presentation of 19.6%, with higher rates among patients who are younger, Black, and have lower socioeconomic status.
Xiao Y, Hsu Y-J, Hannum SM, et al. BMJ Qual Saf. 2025;34(1):8-17.
Medication administration at home can be complex, particularly for older adults taking multiple medications. This article describes the development and evaluation of measures of patient work-system factors in medication management among older adults transitioning from hospital to home. The study found that most adults managed medications without caregivers, faced low self-efficacy, and were unable to complete medication administration tasks – all of which increased reports of feeling overwhelmed and experiencing medication discrepancies. The authors suggest that patient work-system factors be assessed before transitions to home to identify patients at higher risk for poor medication management.
Cheng B, Chan M, Abi-Farrage D, et al. Am J Infect Control. 2024;53(2):181-187.
Maintaining hand hygiene is a critical safety activity for patients, families, and healthcare workers. This study describes a quality improvement project to increase hand hygiene among patients, families, and healthcare workers in two pediatric and obstetrical hospitals. Over the 2-year project period, overall hand hygiene rates improved, but rates among individual units varied.
Wesevich A, Langan E, Fridman I, et al. JAMA Netw Open. 2024;7(12):e2450172.
Bias and the use of stigmatizing language can compromise patient care. This study, conducted with medical students and residents at two academic medical centers, examined the impact of biased versus neutral language on clinical information recall and attitudes towards patients during simulated handoffs. Findings indicate that biased language (particularly blame-based bias) led to less accurate information recall and more negative attitudes towards patients. The authors conclude that using standardized handoffs can help mitigate racial bias and improve the delivery of safe, equitable care.
Musheno D, Harnish M, Roberts J, et al. J Healthc Risk Manag. 2024;Epub Dec 20.
Root cause analysis (RCA) is a common strategy to investigate patient safety events but has been criticized for lack of action and a focus on the individual instead of the system. This article describes the implementation of a root cause analysis and action (RCA2) framework in a community health system. Key aims included building a multidisciplinary team, standardizing event communication, expanding support to affected staff, and decreasing time from event to action implementation.
Bradford A, Tran A, Ali KJ, et al. J Gen Intern Med. . 2024;Epub Oct 22.
AHRQ’s Measure Dx: A Resource to Identify, Analyze, and Learn from Diagnostic Safety Events supports organizational efforts to reduce diagnostic errors. This article describes the efforts of 11 healthcare organizations' implementation and six-month sustainment of Measure Dx. Each of the four case-finding strategies was used, 703 cases were reviewed, and 32% of cases had at least one diagnostic missed opportunity.
Somerville M, Cassidy C, MacPhee S, et al. Jt Comm J Qual Patient Saf. 2025;51(2):135-143.
Patient safety event reports offer unique opportunities for learning and preventing future events. In this study, researchers analyzed 58 precursor safety events and associated follow-up actions in a maternal/pediatric hospital. Using a behavioral change framework, the research team found poor alignment between the underlying causes of the events and the type of intervention/follow-up action in one-third of the cases. These findings highlight the importance of systematic, behavior-informed approaches to improve event reporting and intervention design.
Boskeljon-Horst L, Steinmetz V, Dekker SWA. Healthcare (Basel). 2024;12(20):2046.
Organizations with a just culture aim to balance organizational and individual accountability and responsibility when an error occurs. Through healthcare and non-healthcare examples, this study aims to identify conditions that influence the fair implementation of a restorative just culture. Those conditions were found to coalesce around the overarching principles of leadership quality; public, media, or regulatory attention; and engaging the "second victim."
Shachar C, Drabo EF, Iwashyna TJ, et al. JAMA. 2024;Epub Dec 30.
Pulse oximeters have long been recognized as a patient safety threat to individuals with darker skin tones. Improving accuracy of pulse oximeters is a complex problem with manufacturer, clinical, legal, and regulatory challenges. Interdisciplinary and interagency solutions are proposed.
Ullem BD, Hatlie MJ, Lounsbury O. J Patient Saf. 2025;21(1):34-37.
Patients for Patient Safety US (PFPS-US) is a patient- and family-led organization to improve healthcare in the United States. This article describes the PFPS-US Artificial Intelligence Working Group's priority areas of concern: data integrity and bias, efficacy, payment, and transparency toward shared learning. The PFPS-US AI Working Group stresses patients should have an active role in all stages of development and implementation of AI.
Giebel C, Silva‐Ribeiro W, Watson J, et al. Int J Geriat Psychiatry. 2024;39(10):e6158.
Getting an accurate dementia diagnosis can be a long and challenging road for patients and their families. This systematic review identified 20 studies focused on missed and delayed diagnosis of dementia and dementia subtypes. People with rare subtypes, such as young-onset dementia, experienced significant delays in obtaining an accurate diagnosis, as did minoritized patients. Misdiagnosis was associated with increased costs until the time of correct diagnosis. None of the studies assessed the emotional impact misdiagnosis has on patients and caregivers, which the authors recognize as an urgent area for future research.
Kellett PLR, Franklin BD, Pearce S, et al. BMJ Open Qual. 2024;13(4):e002711.
Medication administration is part of a complex medication use process and a key nursing function. This systematic review explores individual resilience in the context of nursing medication administration. Resilience strategies tended to be real-time, short-term workarounds to deal with system inefficiencies (e.g., manual checking when barcode scanners are down). Additional research is needed on how to translate short-term workarounds into long-term resilience strategies.
No results.
Agency for Healthcare Quality and Research. February 10, 2025, 1:00pm-2:00pm (eastern).
This free webinar will highlight two evidence reports from AHRQ's Making Healthcare Safer IV Reports, a series developed to support patient safety improvement efforts across healthcare systems. Failure To Rescue – Rapid Response Systems reviews rapid response systems’ impacts on patient safety and clinical outcomes, and ways rapid response systems can be implemented effectively. Making Healthcare Safer IV: Opioid Stewardship explores the use of prescribed and ordered opioids, including strategies for using these medications effectively and their unintended consequences.
Agency for Healthcare Quality and Research. Fed Register. December 27, 2024. 89:105605-105606.
Ageism can negatively impact a person’s healthcare experience and the quality of care they receive. This call for public comment seeks to understand the impacts of ageism on healthcare quality, including how ageism affects patient safety, equitable healthcare, and patient outcomes. The comment period is open until March 15, 2025.

This Month’s WebM&Ms

WebM&M Cases
Spotlight Case
Jaenic Lee, MD, Josh Fernelius, MD and William Frick, MD |
A 55-year-old woman with a history of panic attacks, obesity, and untreated hypertension, experienced syncope after feeling flushed and lightheaded. On arrival at the emergency department, she had severely elevated blood pressure and hypoxemia. Diagnostic tests revealed acute heart failure exacerbation with pulmonary edema, marked elevation of brain natriuretic peptide (BNP), and elevated troponin-I. Despite treatment with diuretics and antihypertensives, her condition deteriorated, leading to intubation due to respiratory failure and subsequent cardiac arrest; cardiopulmonary resuscitation resulted in with return of spontaneous circulation. However, she suffered from ischemic stroke and intracranial hemorrhages, ultimately leading to a transition to comfort care and subsequent death. The commentary discusses the contraindications for beta-blockers in the setting of acute decompensated heart failure and appropriate treatment for hypertensive emergencies in the emergency department and intensive care unit. 
WebM&M Cases
Spotlight Case
Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Lewis, MD |
A 54-year-old man with a history of tobacco use presented to the emergency department (ED) with acute chest pain. He was initially stable upon arrival, though with signs of fluid overload and electrolyte abnormalities including hyponatremia and hyperkalemia. Despite treatment including heparin, amiodarone, and metoprolol for atrial fibrillation, and interventions for hyperkalemia, the patient deteriorated rapidly into cardiac arrest characterized by Torsades de pointes, which was mistaken for ventricular fibrillation. Despite resuscitative efforts, he did not achieve return of spontaneous circulation and autopsy revealed sudden cardiac arrest without myocardial infarction as the cause of death. The commentary highlights how the misinterpretation of a common laboratory complication can lead to incorrect treatment and patient harm.
WebM&M Cases
Spotlight Case
Jonathan A. Edlow, MD, FACEP |
A patient in his mid-30s presented to the emergency department (ED) with three weeks of intermittent left-sided headaches, balance issues, and one brief episode of difficulty speaking and moving. On exam, the patient had normal vital signs, neurologic exam, and initial imaging; he was discharged from the ED without consultation from neurology. A few hours later, he suffered a stroke due to left posterior cerebral artery occlusion and vertebral artery dissection, leading to severe neurological deficits after delayed treatment. The commentary highlights the importance of thorough neurological investigation of patients presenting with dizziness and other simultaneous neurological symptoms, the challenges of diagnosing transient ischemic attack (TIA) – particularly in a young, healthy adult, and the limitations of non-contrast brain CT for identifying TIA or early ischemic strokes in patients presenting with dizziness. 

This Month’s Perspectives

Patricia Dykes headshot
Interview
Patricia Dykes, PhD, MA, RN, FAAN, FACMI, Zoe Sousane, BS, Sarah E. Mossburg, RN, PhD |
Dr. Patricia Dykes is the Program Director for Research at the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital and a Professor of Medicine at Harvard Medical School. We spoke with her about falls and fall prevention.
Perspective
Patricia Dykes, PhD, MA, RN, FAAN, FACMI, Zoe Sousane, BS, Sarah E. Mossburg, RN, PhD |
This piece discusses the continuing challenge of preventing falls and explores strategies for preventing falls and falls with injury in both inpatient and outpatient settings.
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