Armstrong Institute for Patient Safety and Quality. October 4 and 6, 2022.
Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model.
Järvinen TLN, Rickert J, Lee MJ. Clin Orthop Relat Res. 2013-2022.
This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.
Vollam S, Gustafson O, Morgan L, et al. Crit Care Med. 2022;50:1083-1092.
This mixed-method study explored the reasons why out-of-hours discharges from the ICU to the ward, and nighttime coverage are associated with poor outcomes. Based on qualitative interviews with patients, family members, and staff involved in the ICU discharge process, this study found that out-of-hours discharges are considered unsafe due to nighttime staffing levels and skill mix. Out-of-hours discharges often occurred prematurely, without adequate handovers, and involved patients who were not physiologically stable, and at risk for clinical deterioration.
Shafer GJ, Singh H, Thomas EJ, et al. J Perinatol. 2022;Epub Mar 4.
Patients in the neonatal intensive care unit (NICU) are at risk for serious patient safety threats. In this retrospective review of 600 consecutive inborn NICU admissions, researchers found that the frequency of diagnostic errors among inborn NICU patients during the first seven days of admission was 6.2%.
Missed or incomplete nursing care can adversely affect care quality and safety. Based on survey responses from 295 frontline nurses in the Philippines, this study explored factors contributing to missed nursing care during the COVID-19 pandemic. Findings suggest that nurses most frequently missed tasks such as patient surveillance, comforting patients, skin care, ambulation, and oral hygiene. The authors suggest that increasing nurse staffing, adequate use of personal protective equipment, and improved safety culture may reduce instances of missed care.
Raghuram N, Alodan K, Bartels U, et al. Virchows Archiv. 2021;478:1179-1185.
Autopsies are an important tool for identifying diagnostic errors. This retrospective study of 821 pediatric cancer deaths found that 10% had a major diagnostic discrepancy between antemortem and postmortem diagnoses. These discrepancies primarily consisted of missed infections, missed cancer diagnoses, and organ complications.
Li Q, Hu P, Kang H, et al. J Nutr Health Aging. 2020;25:492-500.
Missed and delayed diagnosis are a known cause of preventable adverse events. In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury (AKI). However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed AKI. Involvement of intensive care kidney specialists is recommended to increase diagnostic awareness.
Hensgens RL, El Moumni M, IJpma FFA, et al. Eur J Trauma Emerg Surg. 2020;46:1367-1374.
Missed injuries and delayed diagnoses are an ongoing problem in trauma care. This cohort study conducted at a large trauma center found that inter-hospital transfer of severely injured patients increases the risk of delayed detection of injuries. For half of these patients, the new diagnoses led to a change in treatment course. These findings highlight the importance of clinician vigilance when assessing trauma patients.
Kannampallil T, Lew D, Pfeifer EE, et al. BMJ Qual Saf. 2021;30:755-763.
Prior research has found that intraoperative anesthesia handovers can increase patient morbidity and mortality. However, this retrospective cohort study, focused on pediatric surgical patients treated, found that intraoperative anesthesia handovers were not associated with adverse postoperative outcomes.
Bendix J. Med Econ. November 25, 2019;96(23);10-14.
Implicit biases can compromise decision making due to the effect they can have on heuristics, communication and patient/physician communication. This article shares reasons for these biases and shares tactics to minimize their impacts which include being mindful of biases and a personalized approach to patients.
The Pennsylvania Patient Safety Authority is a long-established source of patient safety data analysis and application-focused commentary. Their publishing output aims to generate improvements in their state as well as throughout health care. This open-access publication replaces the quarterly Pennsylvania Patient Safety Advisory newsletter.
Ellis RJ, Schlick CJR, Feinglass J, et al. BMJ Qual Saf. 2020;29:103-112.
This retrospective study of cancer care safety examined the extent to which patients received recommended chemotherapy. A significant proportion of breast, lung, and colorectal cancer patients did not receive chemotherapy; patients who were black and those lacking health insurance or covered by Medicaid were at higher risk. There was marked variability in chemotherapy delivery by location and hospital. The authors conclude that failure to administer chemotherapy is a significant safety gap that should be addressed.
This implementation study describes a new workflow of a telephone call between discharging clinician at an acute care hospital and treating physician at a skilled nursing facility to improve handoffs. Researchers report increasing implementation of this "warm handoff," tempered by concerns about clinician workload and efficiency. The authors conclude that while warm handoffs show promise, the organizational and workflow context could better support this safety strategy.
Patient acuity and the need for interdisciplinary collaboration contribute to patient safety issues in trauma care. This qualitative study explored perceptions of handoff safety in pediatric trauma patients and found a high potential for information loss due to the rapidity of handoffs and the multiple disciplines involved.
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
Dinsdale E, Hannigan A, O'Connor R, et al. Fam Pract. 2019.
Clear communication between primary care physicians and the providers to whom they refer patients has important implications for achieving accurate diagnosis and appropriate treatment plans for patients. In this observational study, researchers included 6603 patients from 68 general medical practices in Ireland, randomly selecting 100 patients from each practice and excluding patients without complete records. They analyzed referral documentation and responses received from subspecialists as well as discharge summaries from hospitalizations over a 2-year period, compared with established national standards. Although 82% of referral letters included current medications, only 30% of response letters and discharge summaries contained medication changes and 33% had medication lists. The authors conclude that significant communication gaps exist between primary and secondary care and that further research is needed to understand how to address them. A past PSNet perspective discussed challenges associated with care transitions.
Cancer patients often rely on family members or paid caregivers to assist with care maintenance at home, such as taking medications and mobility support. This review highlights common safety gaps in home cancer care. The authors suggest that nurses can help assess caregiver knowledge and provide education to address safety issues.
Kapoor A, Field T, Handler S, et al. JAMA Intern Med. 2019;179:1254-1261.
Transitions from hospitals to long-term care facilities are associated with safety hazards. This prospective cohort study identified adverse events in the 45 days following acute hospitalization among 555 nursing home residents, which included 762 discharges during the study period. Investigators found that adverse events occurred after approximately half of discharges. Common adverse events included falls, pressure ulcers, health care–associated infections, and adverse drug events. Most adverse events were deemed preventable or ameliorable. The authors conclude that improved communication and coordination between discharging hospitals and receiving long term-care facilities are urgently needed to address this patient safety gap. A previous WebM&M commentary discussed challenges of nursing home care that may contribute to adverse events.
Improving teamwork and communication is a continued focus in the hospital setting. This toolkit is designed to help organizations create a culture that embeds teamwork into daily practice routines. Topics covered include team leadership, learning and continuous improvement, clarifying roles, structured communication, and support for raising concerns.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.