The PSNet Collection

Joint Commission.

The Speak Up campaign provides sets of materials to enable patients and families to engage in making their health care experiences as safe as possible. Topics covered include safe surgery, pain management, medication safety, and most recently, discrimination reduction. Each topical package includes infographics, videos, instruction guides, and a podcast.

Culture Clash No More: Integration and Coordination of Disease Treatment and Palliative Care

November 30, 2021

A 77-year-old man was diagnosed with a rectal mass. After discussing goals of care with an oncologist, he declined surgical intervention and underwent targeted radiotherapy before being lost to follow up. The patient subsequently presented to Emergency Department after a fall at home and was found to have new metastatic lesions in both lungs and numerous enhancing lesions in the brain. Further discussions of the goals of care revealed that the patient desired to focus on comfort and on maintaining independence for as long as possible. The inpatient hospice team discussed the potential role

Hidden Danger! Insidious Postpartum Bleeding After Emergency Cesarean Delivery.

November 30, 2021

A 32-year-old pregnant woman presented with prelabor rupture of membranes at 37 weeks’ gestation. During labor, the fetal heart rate dropped suddenly and the obstetric provider diagnosed umbilical cord prolapse and called for an emergency cesarean delivery. Uterine atony was noted after delivery of the placenta, which quickly responded to oxytocin bolus and uterine massage.

Reducing failure to rescue rates in a paediatric in-patient setting: a 9-year quality improvement study.

McHale S, Marufu TC, Manning JC, et al. Nurs Crit Care. 2021;Epub Oct 20.

Failure to identify and prevent clinical deterioration can reflect the quality and effectiveness of care. This study used routinely collected emergency event data to identify failure to rescue events at one tertiary children’s hospital. Over a nine-year period, 520 emergency events were identified; 25% were cardiac arrest events and 60% occurred among patients who had been admitted for more than 48 hours. Over the nine-year period, failure to rescue events decreased from 23.6% to 2.5%.

Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration.

Walton E, Charles M, Morrish W, et al. J Patient Saf. 2021;Epub Sep 28.

Dialysis is a common procedure that carries risks if not performed correctly. This study analyzed dialysis-related bleeding events reported to the Veterans Health Administration Patient Safety Authority over an 18-year period. The analysis identified four areas of focus to reduce bleeding events – (1) the physical location and equipment used, (2) staff commitment to standardization and attention to detail (to reduce unwitnessed bleeding events), (3) mental status of the patient, and (4) the method for hemodialysis delivery.

Inattentional blindness in anesthesiology: a gorilla is worth one thousand words.

De Cassai A, Negro S, Geraldini F, et al. PLoS One. 2021;16(9):e0257508.

Inattentional blindness occurs when individuals miss an unexpected event due to competing attentional tasks. This study asked anesthesiologists to review the anesthetic management of five simulated cases, one of which included the image of a gorilla in the radiograph, to evaluate inattentional blindness. Only 4.9% of respondents spotted the gorilla, indicating inattentional blindness is common in anesthesia; the authors suggest several strategies to reduce this error.

Abdominal pain in the emergency department: missed diagnoses.

Halsey-Nichols M, McCoin N. Emerg Med Clin North Am. 2021;39(4):703-717.

Diagnostic errors among patients presenting to the emergency department (ED) with abdominal pain are common. This article summarizes the factors associated with missed diagnoses of abdominal pain in the ED, the types of abdominal pain that are commonly misdiagnosed, and recommended steps for discharging a patient with abdominal pain without a final diagnosis.

How low can they go? Rural hospitals weigh keeping obstetric units when births decline.

Huff C. Kaiser Health News. November 12, 2021.

This article discusses the challenge of providing safe maternity care in rural environments when demand for service cannot support its cost, and keeping teams actively experienced in provision of reliable maternal care.

Pediatric medication errors and reduction strategies in the perioperative period.

Bekes JL, Sackash CR, Voss AL, et al. AANA J. 2021;89(4):319-324.

Pediatric medication errors during anesthesia can lead to significant harm and are largely preventable. This review identifies several themes around medication errors including dosing and incorrect medication. Successful error reduction strategies, such as standardized labeling and pre-filled syringes, are also described.

'It depends': The complexity of allowing residents to fail from the perspective of clinical supervisors.

Klasen JM, Teunissen PW, Driessen EW, et al. Med Teach. 2021;Epub Oct 13.

Previous research has found that error permission (allowing errors to arise naturally and not preventing them) is a common strategy used in clinical training. This qualitative study with supervising physicians found that decisions to allow residents to fail are often made in the moment and are influenced by the patient, supervisor, trainee, and environmental factors.

From HRO to HERO: making health equity a core system capability.

Moy E, Hausmann LRM, Clancy CM. Am J Med Qual. 2021;Epub Sep 11.

Shortcomings in health equity represent systemic weaknesses in health care. This commentary suggests that actions to reduce disparities be added to the components of high reliability organizations (HRO) to facilitate an expansion of the HRO concept to address the threat to patient safety that inequity represents.

SECUre: a multicentre survey of the safety of emergency care in UK emergency departments.

Flowerdew L, Tipping M. Emerg Med J. 2021;38(10):769-775.

This study sought to validate an emergency department (ED) safety questionnaire developed in the United States, and adapted for use in the UK. The survey was validated by 33 patient safety leads and used in a multi-center survey. Analysis highlighted risks and positive factors (e.g., positive safety culture) present in surveyed EDs.

Impact of the WHO Surgical Safety Checklist relative to its design and intended use: a systematic review and meta-meta-analysis.

Sotto KT, Burian BK, Brindle ME. J Am Coll Surg. 2021;Epub Oct 1.

The World Health Organization (WHO) Surgical Safety Checklist has been implemented in healthcare systems around the world. This systematic review and thematic analysis concluded that the surgical safety checklist positively impacts clinical outcomes (surgical outcomes and mortality), process measures, team dynamics, and communication, as well as safety culture. The authors note that the checklist was negatively associated with efficiency and workload; included studies often noted that checklist users felt the checklist slowed down processes within the operating room

Artificial intelligence for identifying the prevention of medication incidents causing serious or moderate harm: an analysis using incident reporters' views.

Härkänen M, Haatainen K, Vehviläinen-Julkunen K, et al. Int J Environ Res Public Health. 2021;18(17):9206.

Building on previous research on the use of text mining related to medication administration error incidents, researchers in this study found that artificial intelligence can be used to accurately classify the free text of medication incident reports causing serious or moderate harm, to identify target risk management areas.

NCICLE Pathways to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care, 2021.

Chicago, IL: National Collaborative for Improving the Clinical Learning Environment; 2021. ISBN: 9781945365416.

Health care provision requires continuous learning to enhance skills, collaboration, and system awareness. This report discusses characteristics of an environment that nurtures learning across disciplines in health care. It centers on 6 areas of focus: patient safety, quality, teaming, supervision, well-being, and professionalism.

Management of the deteriorating adult patient: does simulation-based education improve patient safety?

Bennion J, Mansell SK. Br J Hosp Med (Lond). 2021;82(8):1-8.

Many strategies have been developed to improve recognition of, and response, to clinically deteriorating patients. This review found that simulation-based educational strategies was the most effective educational method for training staff to recognize unwell patients. However, the quality of evidence was low and additional research into simulation-based education is needed.

Patient and caregiver factors in ambulatory incident reports: a mixed-methods analysis.

Sharma AE, Huang B, Del Rosario JB, et al. BMJ Open Qual. 2021;10(3):e001421.

Patients and caregivers play an essential role in safe ambulatory care. This mixed-methods analysis of ambulatory safety reports identified three themes related to patient and caregivers factors contributing to events – (1) clinical advice conflicting with patient priorities, (2) breakdowns in communication and patient education contributing to medication adverse events, and (3) the fact that patients with disabilities are vulnerable to due to the external environment.

When we're all responsible for a patient's death, no one is.

Prasad V, Medpage Today. November 16, 2021.

The issue of system versus individual accountability can challenge the orientation of safety improvement efforts. This opinion piece discusses the importance of physician recognition of decision making mistakes and the downside of the evolution of morbidity and mortality conferences away from that approach.

Examining the meaning of the language used to communicate the nursing hand-off.

Galatzan BJ, Carrington JM. Res Nurs Health. 2021;44(5):833-843.

During handoffs, nurses are exposed to a variety of interruptions and distractions which may lead to cognitive overload. Using natural language processing, researchers analyzed ten audio-recorded change of shift handoffs to estimate the cognitive load experienced by nurses. Nurses’ use of concise language has the potential to decrease cognitive overload and improve patient outcomes.

Addressing health care disparities by improving quality and safety.

Sentinel Event Alert. Nov 10 2021;(64):1-7.

Health care disparities emerging as a core patient safety issue. This alert introduces strategies to align organizational and patient safety strategic goals, such as collection and analysis of community-level performance data, adoption of diversity and inclusion as a precursor to improvement, and development of business cases to support inequity reduction initiatives.

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