Richie CD, Castle JT, Davis GA, et al. Angiology. 2022;73:712-715.
Hospital-acquired venous thromboembolism (VTE) continues to be a significant source of preventable patient harm. This study retrospectively examined patients admitted with VTE and found that only 15% received correct risk stratification and appropriate management and treatment. The case review found that patients were commonly incorrectly stratified, received incorrect pharmaceutical treatment, or inadequate application of mechanical prophylaxis (e.g., intermittent compression).
Trigger tools alert patient safety personnel to potential adverse events (AE) which can then be followed up with retrospective chart review. This review sought to understand the variability in adverse event detection in acute care and study characteristics that may explain the variation. Fifty-four studies were included with a wide range of AEs detected per 100 admissions. The authors suggest developing guidelines for studies reporting on AEs identified using trigger tools to decrease study heterogeneity.
Lim Fat GJ, Gopaul A, Pananos AD, et al. Geriatrics (Basel). 2022;7:81.
The risk of adverse events increases with prolonged hospital stays. This descriptive study examined adverse events among older patients with extended hospital admissions pending transfer to long-term care (LTC) settings at two Canadian hospitals. Analyses showed that patients were designated as “alternate level of care” (ALC) for an average of 56 days before transfer to LTC and adverse events such as falls and urinary tract infections were common.
Moore T, Kline D, Palettas M, et al. J Nurs Care Qual. 2022;Epub Aug 19.
Fall prevention is a safety priority in hospital settings. This study found that Smart Socks – socks containing pressure sensors that detect when a patient is trying to stand up – reduced fall rates among patients at risk of falls in one hospital’s neurological and neurosurgical department. Over a 13-month period, investigators observed a decreased fall rate (0 per 1000 patient days) among patients wearing Smart Socks compared to prior to intervention implementation (4 per 1000 patient days).
Tsilimingras D, Natarajan G, Bajaj M, et al. J Patient Saf. 2022;18:462-469.
Post-discharge events, such as medication errors, can occur among pediatric patients discharged from inpatient settings to home. This prospective cohort, including infants discharged from one level 4 NICU between February 2017 and July 2019, identified a high risk for post-discharge adverse events, (including procedural complications and adverse drug events) and subsequent emergency department visits or hospital readmissions. Nearly half of these events were due to management, therapeutic, or diagnostic errors and could have been prevented.
Stockwell DC, Kayes DC, Thomas EJ. J Patient Saf. 2022;18:e877-e882.
Striving for “zero harm” in healthcare has been advocated as a patient safety goal. In this article, the authors discuss the unintended consequences of “zero harm” goals and provide an alternative approach emphasizing learning and resilience goals (leveled-target goal setting, equal emphasis goals, data-driven learning, and developmental – rather than performance – goals).
The Centers for Medicare & Medicaid Services (CMS) provides individual and composite quality and safety ratings (i.e., star ratings) for hospitals and other healthcare facilities on its Care Compare website. This study evaluated three alternative methods for rating facilities and compared them to the CMS star ratings. Hospitals were frequently assigned a different star rating using the alternate methods, typically between adjacent star categories.
Plunkett A, Plunkett E. Paediatr Anaesth. 2022;Epub Jun 18.
Safety-I focuses on identifying factors that contribute to incidents or errors. Safety-II seeks to understand and learn from the many cases where things go right, including ordinary events, and emphasizes adjustments and adaptations to achieve safe outcomes. This commentary describes Safety-II and complementary positive strategies of patient safety, such as exnovation, appreciative inquiry, learning from excellence, and positive deviance.
Ahsani-Estahbanati E, Sergeevich Gordeev V, Doshmangir L. Front Med (Lausanne). 2022;9:875426.
Hospital-acquired conditions impact not only patient morbidity and mortality, but are also a significant financial burden. This review identified eight categories of hospital-acquired conditions (i.e., overall medical error, medication error, diagnostic error, patient falls, healthcare-associated infections, transfusion and testing errors, surgical error, and patient suicide) and more than 100 proposed interventions addressing those conditions.
Kaplan HJ, Spiera ZC, Feldman DL, et al. J Am Coll Surg. 2022;235:494-499.
Unintentionally retained surgical items (RSI) can have a devastating impact on patient health and safety. One method to reduce the incidence of RSI is radiofrequency (RF) detection. Nearly one million operations in New York state were analyzed for the rate of RSI before and after the use of RF was required and simultaneous TeamSTEPPS training was provided. The incidence of RF-detectable items was significantly reduced, but the rate of non-RF-detectable items was not.
Thiele L, Flabouris A, Thompson C. PLoS ONE. 2022;17:e0269921.
Patient and family engagement is essential for safe healthcare. This single-site study found that while most clinicians perceived that patients and families are able to recognize clinical deterioration, clinicians expressed less favorable perceptions towards escalation processes when patients or families have concerns about clinical deterioration.
Griffey RT, Schneider RM, Todorov AA. Ann Emerg Med. 2022;Epub Aug 1.
Trigger tools are a novel method of detecting adverse events. This article describes the location, severity, omission/commission, and type of adverse events retrospectively detected using the computerized Emergency Department Trigger Tool (EDTT). Understanding the characteristics of prior adverse events can guide future quality and safety improvement efforts.
Moody A, Chacin B, Chang C. Curr Opin Anaesthesiol. 2022;35:465-471.
Hospital-acquired pressure injuries are considered a never event. This review presents strategies to prevent pressure injuries in the nonoperating room anesthesia (NORA) population (e.g., patients on ventilators). Proper positioning of the patient, with bolsters and padding, are illustrated.
Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:B2-B10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.
Coffey M, Marino M, Lyren A, et al. JAMA Pediatr. 2022;176:924-932.
The Partnership for Patients (P4P) program launched hospital engagement networks (HEN) in 2011 to reduce hospital-acquired harms. This study reports on the outcomes of eight conditions from one HEN, Children's Hospitals' Solutions for Patient Safety (SPS). While the results do show a reduction in harms, the authors state earlier claims of improvement may have been overstated due to failure to not adjust for secular improvements. The co-director of Partnership for Patients, Dr. Paul McGann, was interviewed in 2016 for a PSNet perspective.
de Kraker MEA, Tartari E, Tomczyk S, et al. Lancet Infect Dis. 2022;22:835-844.
Hand hygiene is known to be a critical part of effective infection prevention and control. This study examined the level of hand hygiene implementation using the WHO Hand Hygiene Self-Assessment Framework global survey and its drivers. There were 3,206 organizations from 90 different countries that responded. Over half of the participants indicated they had intermediate hand hygiene implementation, particularly those with higher county income levels and facility funding. Implementation of alcohol-based hand rub stations was an important system change associated with improved scores.
Samal L, Khasnabish S, Foskett C, et al. J Patient Saf. 2022;18:611-616.
Adverse events can be identified through multiple methods, including trigger tools and voluntary reporting systems. In this comparison study, the Global Trigger Tool identified 79 AE in 88 oncology patients, compared to 21 in the voluntary reporting system; only two AE were identified by both. Results indicate multiple sources should be used to detect AE.
Eldridge N, Wang Y, Metersky M, et al. JAMA. 2022;328:173.
Improving patient safety in hospitals is a longstanding national priority. Using longitudinal Medicare data from 2010 to 2019, this study identified a significant decrease in the rates of adverse events (e.g., adverse drug events, hospital-acquired infections, postoperative adverse events, hospital-acquired pressure ulcers, falls) over time among patients hospitalized for four common conditions – acute myocardial infarction, heart failure, pneumonia, and surgical procedures.
Halvorson EE, Thurtle DP, Easter A, et al. Acad Pediatr. 2022;22:747-753.
Previous research has identified an association between patient weight and certain adverse events and patient safety threats, such as medication dosing errors and airway management. After analyzing data for pediatric patients discharged from a single children’s hospital, researchers in this study did not identify an association between patient body mass index (BMI) and the rate, severity, or preventability of adverse events.
Hemmelgarn C, Hatlie MJ, Sheridan S, et al. J Patient Saf Risk Manage. 2022;27:56-58.
This commentary, authored by patients and families who have experienced medical errors, argues current patient safety efforts in the United States lack urgency and commitment, even as the World Health Organization is increasing its efforts. They call on policy makers and safety agencies to collaborate with the Patients for Patient Safety US organization to move improvement efforts forward.
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