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December 6, 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
Blatter C, Osińska M, Simon M, et al. Int J Nurs Stud. 2023;150:104641.
Minimum nurse staffing levels have been promoted by researchers and legislators to reduce adverse events and improve patient safety in both hospitals and nursing homes. While this review of reviews found higher nurse staffing was generally associated with positive outcomes, results varied between staffing groups (e.g., registered nurses compared to licensed vocational/practical nurses or nursing assistants). The authors identified several methodological challenges and described how study design modifications could yield a more robust examination of the causal relationship between staffing and outcomes.
Montalmant KE, Ettinger AK. J Racial Ethn Health Disparities. 2023;Epub Nov 13.
The increased risk of maternal morbidity and mortality among Black women in the United States is a patient safety and public health crisis. This literature review of 42 articles highlights the importance of cultural competence and disparities training for obstetric providers to reduce maternal mortality and morbidity among Black women. The authors also highlight the need for increased awareness regarding the increased risk of cardiovascular diseases among pregnant Black women.
Simon LT, Van Buren T. NEJM Catal Innov Care Deliv. 2023;4.
Achieving zero preventable harm is an ongoing goal for healthcare organizations. This article describes one large, multistate community health system’s experience decreasing serious adverse events through implementation of high-reliability leadership, promoting human error prevention behaviors, and accelerating learning through a structured approach to cause analysis at both the individual and systems levels.
Zhong A, Amat MJ, Anderson TS, et al. JAMA Netw Open. 2023;6:e2343417.
Increased use of telehealth presents both benefits and potential threats to patient safety. In this study of 4,133 patients, researchers found that orders for colonoscopies or cardiac stress tests and dermatology referrals placed during telehealth visits were less likely to be completed within the designated timeframe compared to those ordered during in-person visits (43% vs. 58%). Not completing test or referrals within the recommended timeframe can increase the risk of delayed diagnoses and patient harm.
Bushuven S, Bentele M, Bentele S, et al. J Med Syst. 2023;47:123.
ChatGPT has emerged as a potentially useful tool for clinicians and the public in obtaining heath advice and diagnosis. In this study, six iterations of 22 pediatric emergency vignettes were entered into ChatGPT (total of 132 scenarios) to assess diagnostic accuracy, emergency call advice, and validity of advice given. ChatGPT correctly recommended contacting medical professionals in all cases but only advised calling emergency medical services (EMS) or 911 in 12 of the 22 scenarios. The correct diagnosis was made in 94% of cases, consistent with other research into ChatGPT. Considerably more research is required before ChatGPT could be recommended for diagnostic advice.
Zhong A, Amat MJ, Anderson TS, et al. JAMA Netw Open. 2023;6:e2343417.
Increased use of telehealth presents both benefits and potential threats to patient safety. In this study of 4,133 patients, researchers found that orders for colonoscopies or cardiac stress tests and dermatology referrals placed during telehealth visits were less likely to be completed within the designated timeframe compared to those ordered during in-person visits (43% vs. 58%). Not completing test or referrals within the recommended timeframe can increase the risk of delayed diagnoses and patient harm.
Hibbert PD, Stewart S, Wiles LK, et al. Int J Qual Health Care. 2023;Epub Oct 17.
Quality improvement and patient safety initiatives require incredible human and financial resources, they so must be selected carefully to achieve the greatest return on investment. This article describes important considerations for hospital leaders when selecting and implementing initiatives. Safety culture, policies and procedures, supporting staff, and patient engagement were notable themes. The included "patient safety governance model" provides a framework to develop patient safety policy.
Hattingh HL, Edmunds C, Gillespie BM. J Pharm Policy Pract. 2023;16:127.
Remote or virtual patient care was an increasingly common strategy during the COVID-19 pandemic to keep patients safe and ensure adequate inpatient resources for patients unable to be cared for virtually. In this study, hospital physicians, pharmacists, and nurses described medication challenges associated with patients receiving virtual care (i.e., hospital-level care at home or hotel). Participants described challenges with lack of clarity on who is responsible for the patient's usual home medications, disruptions to typical workflow, and difficulties with transition from inpatient to virtual care.
Wong BJ, Nassar AK, Earley M, et al. JAMA Netw Open. 2023;6:e2341182.
Mitigating error and encouraging teamwork is essential in complex surgical environments. In this study, researchers found that surgical caps labeled with names and roles fostered a climate of safety and inclusion among perioperative clinicians.
Etheridge JC, Moyal-Smith R, Yong TT, et al. JAMA Surg. 2023;Epub Nov 15.
Surgical safety checklists have been credited with improving perioperative patient outcomes, but numerous studies have shown implementation to be variable across settings and surgical specialties. This study aimed to redesign and reimplement the surgical safety checklist in two academic hospitals. Item completion and fidelity improved after reimplementation and exploratory analysis suggests improved patient outcomes (e.g., serious complications).
Williams C. Emerg Nurse. 2023;31:34-41.
Overcrowding in the emergency department (ED) and boarding can place patients at increased risk for adverse events. This article outlines how ED overcrowding occurs and provides several approaches to mitigate risks and enhance patient safety in overcrowded EDs, such as checklists, huddles, and resource allocation.
List JM, Russell LE, Hausmann LRM, et al. Jt Comm J Qual Patient Saf. 2023;Epub Oct 10.
Unmet health-related social needs (HRSNs; e.g., housing instability, food insecurity) and healthcare disparities can place patients at increased risk for patient safety incidents and poor outcomes. This article describes how existing Veterans Health Administration (VHA) initiatives to address HRSNs and disparities are being leveraged to address new Joint Commission standards to improve health care equity.
Simon LT, Van Buren T. NEJM Catal Innov Care Deliv. 2023;4.
Achieving zero preventable harm is an ongoing goal for healthcare organizations. This article describes one large, multistate community health system’s experience decreasing serious adverse events through implementation of high-reliability leadership, promoting human error prevention behaviors, and accelerating learning through a structured approach to cause analysis at both the individual and systems levels.
Sittig DF, Yackel EE, Singh H. J Gen Intern Med. 2023;38:940-942.
Large-scale technology modifications can contribute to organizational disfunction. This commentary discusses five approaches to managing disruption associated with electronic health record modernization that establish cultural, functionality, staff, design, and monitoring conditions to reduce stress and the potential for patient harm during technology improvements.
Schlesinger M, Grob R. Hastings Cent Rep. 2023;53:s22-s32.
Involvement in patient safety incidents can erode patient trust in their own physicians and the healthcare system. This article summarizes the estimated frequency of lost trust after patient safety incidents, external factors contributing to mistrust, and approaches to restoring trust after incidents.
Leon C, Hogan H, Jani YH. BMJ Qual Saf. 2023;Epub Nov 3.
Errors associated with high-risk medications (HRM) like insulin and anticoagulants carry a greater risk for harm. The purpose of this scoping review was to identify measures evaluating the safety of HRM during transitions of care. Measures were mapped to frameworks (e.g., Donabedian) and whether measures were reactive, proactive, or real-time. The authors describe ways technology can improve how the measures are implemented.
Ahmed M, Suhrawardy A, Olszewski A, et al. J Am Acad Orthop Surg. 2023;Epub Sep 19.
Overlapping surgeries, where one attending surgeon supervises two surgeries with noncritical portions occurring simultaneously, are generally considered as safe as non-overlapping surgeries. This review identified 11 studies into safety outcomes of overlapping orthopedic surgeries involving 34,494 overlapping surgeries. Consistent with prior research, although overlapping surgeries tended to have increased surgical times, short-term outcomes were no different than non-overlapping; one study showed increased risk for adverse events at one year. The authors suggest future research into overlapping robotic-assisted surgeries.
Ledger TS, Brooke-Cowden K, Coiera E. J Am Med Inform Assoc. 2023;30:2064-2071.
Computerized provider order entry (CPOE) systems can reduce medication errors by alerting prescribers to a variety of potential adverse events. However, too many alerts may result in alert fatigue. This scoping review identified 16 studies on interventions to reduce alert fatigue. Most interventions focused on drug-drug interactions. A decrease in the quantity and frequency of alerts was seen as a positive outcome, however only four of the studies reported any patient safety outcomes.
Montalmant KE, Ettinger AK. J Racial Ethn Health Disparities. 2023;Epub Nov 13.
The increased risk of maternal morbidity and mortality among Black women in the United States is a patient safety and public health crisis. This literature review of 42 articles highlights the importance of cultural competence and disparities training for obstetric providers to reduce maternal mortality and morbidity among Black women. The authors also highlight the need for increased awareness regarding the increased risk of cardiovascular diseases among pregnant Black women.
Blatter C, Osińska M, Simon M, et al. Int J Nurs Stud. 2023;150:104641.
Minimum nurse staffing levels have been promoted by researchers and legislators to reduce adverse events and improve patient safety in both hospitals and nursing homes. While this review of reviews found higher nurse staffing was generally associated with positive outcomes, results varied between staffing groups (e.g., registered nurses compared to licensed vocational/practical nurses or nursing assistants). The authors identified several methodological challenges and described how study design modifications could yield a more robust examination of the causal relationship between staffing and outcomes.
International Meeting/Conference
Sepsis Alliance. December 14, 2023, 12:00 - 3:30 PM (eastern).
Healthcare-associated infections (HAIs) are a pervasive and preventable contributor to sepsis and patient harm. This session will discuss areas of focus in the HAI spectrum such as central line–associated bloodstream infections, or CLABSIs. The presenters will review prevention strategies and documentation to support their use in the care environment.
Dwyer D, See P. ABC News. November 28, 2023.
Lack of respect for the concerns of patients and sensitivity to their situation detract from their safety and trust in the health care system. This story relates firsthand experience of maternal mistreatment of those harmed while receiving care.
Book/Report
Rockville, MD: Agency for Healthcare Research and Quality; 2023.
The application of evidence in real situations helps to embed innovation across systems and sustain care improvement. This collection of project highlight reports shares descriptions of implementation projects and research funded by AHRQ. Topics covered include patient engagement, health information technology, and healthcare facility design.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Rachel Ann Hight, MD |
This case describes a 55-year-old woman who sustained critical injuries after a motor vehicle crash and had a lengthy hospitalization. On hospital day 30, a surgeon placed a percutaneous endoscopic gastrostomy (PEG) tube in the intensive care unit (ICU) after computed tomography (CT) scan showed no interposed bowel between the stomach and the anterior abdominal wall. After the uncomplicated PEG placement, the surgeon cleared the patient’s team to advance tube feeds as tolerated. After several weeks of poorly tolerated tube feedings, the interventional radiology team reviewed a CT scan which had been obtained by another service 6 days after the PEG was placed and noted (for the first time) that the gastrostomy tube traversed the liver. Insufficient communication and fragmented care coordination across care settings contributed to poor management of the malpositioned PEG tube. The commentary underscores the importance of clear documentation of complications, highlights best practices to mitigate risks during patient care transition, and the importance of using multiple communication approaches to ensure appropriate continuity of care.
WebM&M Cases
Christian Bohringer, MBBS, and Sharon Ashley, MD. |
A 38-year-old woman with class 3 obesity required removed of a gastric balloon under general anesthesia. She required a relatively large dose of rocuronium for endotracheal intubation, and she was given intravenous sugammadex (200 mg) at the end of the procedure to reverse the neuromuscular block. A quantitative neuromuscular block monitor was not used, but reliance was placed on clinical signs. Shortly after arrival in the post-anesthesia care unit, she couldn’t move or open her eyes and became jittery with low oxygen saturation. Quantitative blockade monitoring revealed a “train of four” (TOF) ratio less than 70%, so she was given another 200 mg of intravenous sugammadex with return of normal motor function.
WebM&M Cases
Luciano Sanchez, PharmD and Patrick Romano, MD, MPH |
An 81-year-old man was admitted to the intensive care unit (ICU) with a gastrointestinal bleed and referred for a diagnostic colonoscopy. The nurse preparing the patient for the colonoscopy mistakenly selected a jug of dialysis liquid rather than a polyethylene glycol solution commonly used to clean the colon for colonoscopy. When the barcode on the jug of dialysis liquid did not scan, the nurse called the hospital pharmacy for assistance and was provided a new barcode via a tube system. After the patient had difficulty drinking the solution, the nurse gave the rest of the liquid through a feeding tube bag. The medication mix-up was identified around midnight and the patient died about 7 hours later.
This Month’s Perspectives
Perspectives on Safety
Joan Stanley, PhD, NP, FAAN, FAANP; Bryan M. Gale, MA; Sarah E. Mossburg, RN, PhD |
This piece discusses how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.
Interview
Joan Stanley, PhD, NP, FAAN, FAANP |
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