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Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic

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January 12, 2022

This piece discusses patient safety challenges that arose as a result of the unique care circumstances surrounding the COVID-19 pandemic, particularly at the height of the pandemic in 2020.

A simulation systems testing program using HFMEA methodology can effectively identify and mitigate latent safety threats for a new on-site helipad.

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Holmes J, Chipman M, Barbour T, et al. Jt Comm J Qual Patient Saf. 2022;48:12-24.

Air medical transport carries unique patient safety risks. In this study, researchers used simulation training and healthcare failure mode and effect analysis (HFMEA) to identify latent safety threats related to patient transport via helicopter. This approach identified 31 latent safety threats (18 were deemed critical) related to care coordination, facilities, equipment, and devices.

Learning from diagnostic errors to improve patient safety when GPs work in or alongside emergency departments: incorporating realist methodology into patient safety incident report analysis.

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Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21:139.

Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.

Quality and safety in hospital pediatrics during COVID-19: a national qualitative study.

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De Angulo NR, Penwill N, Pathak PR, et al. Hosp Pediatr. 2021;Epub Dec 24.

This study explored administrator, physician, nurse, and caregiver perceptions of safety in pediatric inpatient care during the first months of the COVID-19 pandemic. Participants reported changes in workflows, discharge and transfer process, patient and family engagement, and hospital operations.

Don't go to the hospital alone: ensuring safe, highly reliable patient visitation.

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Gandhi TK. Jt Comm J Qual Patient Saf. 2022;48:61-64.

Families and caregivers play an important role in ensuring patient safety. At the start of the COVID-19 pandemic and, to a lesser extent, during surges, family and caregiver visitation was severely restricted. This commentary advocates reassessing risks and benefits of restricted visitation, both during the pandemic and beyond.

Integrating principles of safety culture and just culture into nursing homes: lessons from the pandemic.

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Gaur S, Kumar R, Gillespie SM, et al. J Am Med Dir Assoc. 2021;23:241-246.

A culture of safety in nursing homes has been linked to improved resident care. The authors describe how the alignment of regulatory oversight and surveys could integrate with just culture to improve resident safety.

Where trust flourishes: perceptions of clinicians who trust their organizations and are trusted by their patients.

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Linzer M, Neprash HT, Brown RL, et al. Ann Fam Med. 2021;19:521-526.

Using data from the Healthy Work Place trial, this study explored characteristics associated with high clinician and patient trust. Findings suggest that trust is higher when clinicians perceived their organizational cultures as emphasizing quality, communication and information, cohesiveness, and value alignment between clinicians and leaders.

Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review.

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Lo L, Rotteau L, Shojania KG. BMJ Open. 2021;11:e055247.

Situation, Background, Assessment, Recommendation (SBAR) is a mnemonic technique used to avoid communication failures during handoffs. This systematic review found that fidelity with SBAR is highest in classroom settings, but that studies in clinical contexts either did not achieve sufficient improvements in fidelity or did not assess fidelity.

Encouraging patients to speak up about problems in cancer care.

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Mazor KM, Kamineni A, Roblin DW, et al. J Patient Saf. 2021;17:e1278-e1284.

Patient engagement and encouraging speaking up can promote safety. This randomized study found that patients undergoing cancer treatment who were randomized to an active outreach program were significantly more likely to speak up and report healthcare concerns than patients in the control group.

Evaluation of clinical practice guidelines on fall prevention and management for older adults: a systematic review.

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Montero-Odasso MM, Kamkar N, Pieruccini-Faria F, et al. JAMA Netw Open. 2021;4:e2138911.

Fall prevention in healthcare settings is a patient safety priority. This systematic review found that most clinical practice guidelines provide consistent recommendations for fall prevention for older adults. Guidelines consistently recommend strategies such as risk stratification, medication review, and environment modification.

Validation of the second victim experience and support tool-revised in the neonatal intensive care unit.

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Winning AM, Merandi J, Rausch JR, et al. J Patient Saf. 2021;17:531-540.

Healthcare professionals involved in a medical error often experience psychological distress. This article describes the validation of a revised version of the Second Victim Experience and Support Tool (SVEST-R), which was expanded to include measures of resilience and desired forms of support.

Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center Survey: 2021 User Database Report.

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Famolaro T, Hare R, Tapia A, Yount et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0004.

Ambulatory surgery centers harbor unique characteristics that affect safety culture. This analysis from the Agency for Healthcare Research and Quality (AHRQ) shares results of 235 ambulatory surgery centers (ASCs) participating in the Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey. Most respondents (92%) rated their organization as committed to learning and continuous improvement.

Patient Safety.

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Dean J, Subbe C, eds. Future Healthc J. 2021;8(3):e559-e618.

Full realization of the patient voice as a resource for safety is challenging. This special section provides global perspectives examining cultural, organizational, and system-focused opportunities to fully use patient knowledge in improvement initiatives.

Safety, Equity and Engagement in Maternity Services.

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Newcastle upon Tyne, UK: Care Quality Commission; September 2021.

The safety of maternity care is threatened by inequity. This report analyzes a set of United Kingdom investigation reports to identify issues affecting maternity care to determine their prevalence elsewhere in the system. Problems identified include poor leadership and teamwork, as well as learning and cross-service collaboration.

In conversation with Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO

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January 12, 2022

Patient Safety Organizations (PSOs) are organizations dedicated to improving patient safety and healthcare quality that serve to collect and analyze data voluntarily reported by healthcare providers to promote learning.

Coronavirus Disease 2019 (COVID-19) and Diagnostic Error

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January 11, 2022

Diagnostic error has been increasingly recognized as an important and evolving patient safety issue. This Primer applies well-established principles of diagnostic error and improvement of diagnostic accuracy to the topic of COVID-19.

The Next Step: Use of a Pre-Operative Checklist to Prevent Missteps

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January 7, 2022

A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several different providers (pre-operative nurse, resident physician, attending physician, and anethesiology team) to help prepare her for the procedure. In the OR, the surgical team performed two separate time-outs while the patient was being prepped, placed under general anesthesia, and draped.

Improving allergy documentation: a retrospective electronic health record system-wide patient safety initiative.

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Li L, Foer D, Hallisey RK, et al. J Patient Saf. 2022;18:e108-e114.

Despite the introduction of computerized provider order entry into electronic health records, providers still frequently use free-text fields to communicate important information which introduces a patient safety risk. One healthcare system searched allergy-related free-text fields, identifying more than 242,000 entries. Approximately 131,000 were manually or automatically remediated (e.g., “latex from back brace” and “gloves” were coded “latex-natural rubber”).

Sentinel Events.

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Joint Commission.

Sentinel events are a primary indicator of patient safety in hospitals that enable learning through reporting to the Joint Commission. This website provides access to statistics, alerts, policies and tools to assist organizations in using sentinel events for their medical error reduction efforts.

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