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The Consequences of Miscommunication Regarding a Possible Artifact

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June 30, 2021

A 52-year-old man complaining of intermittent left shoulder pain for several years was diagnosed with a rotator cuff injury and underwent left shoulder surgery. The patient received a routine follow-up X-ray four months later.

Assessing reasons for decreased primary care access for individuals on prescribed opioids: an audit study.

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Lagisetty P, Macleod C, Thomas J, et al. Pain. 2021;162:1379-1386.

Inappropriate prescribing of opioids is a major contributor to the ongoing opioid epidemic. This study involved simulated patients with chronic opioid use who called primary care clinics in need of a new provider because their previous physician had retired or stopped prescribing opioids. Findings indicate that primary care providers were generally unwilling to prescribe opioids to patients whose histories are suggestive of misuse, which may raise access to care concerns and cause potential unintended harm for some patients.

TeamSTEPPS for the COVID-19 Crisis.

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AHA Team Training.

The COVID-19 crisis requires cooperation and coordination of organizations and providers to address the persistent challenges presented by the pandemic. This on-demand video collection reinforces core TeamSTEPPS; methods that enhance clinician teamwork and communication skills to manage care safety during times of crisis.

Implementation of a parent-centered approach to the preinduction checklist in pediatric surgery.

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Arshad SA, Ferguson DM, Garcia EI, et al. J Surg Res. 2021;257:455-461.

Engaging patients and families is an important strategy in ensuring safe health care delivery. In this prospective, observational study, use of a parent-centered script did not improve parent engagement during the preinduction checklist and resulted in an expected decline in checklist adherence.

Missed acute coronary syndrome during telephone triage at out-of-hours primary care: lessons from a case-control study.

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Erkelens DC, Rutten FH, Wouters LT, et al. J Patient Saf. 2022;18:40-45.

Delays in diagnosis and treatment during after-hours care pose serious threats to patient safety. This case-control study compared missed acute coronary syndrome (ACS) cases to other cases with chest discomfort occurring during out-of-hours services in primary care. Predictors of missed ACS included the use of cardiovascular medication, non-retrosternal chest pain, and consultation of the supervising general practitioner.

Implicit bias in stroke care: a recurring old problem in the rising incidence of young stroke.

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Bhat A, Mahajan V, Wolfe N. J Clin Neurosci. 2021;85:27-35.

Misdiagnosis, variation in treatment of stroke and gaps in secondary prevention in young patients can result in adverse outcomes. This article discusses the possible causes of implicit bias in stroke care in this population, the effects of bias on patient outcomes, and interventions to circumvent implicit bias.

Speaking up about patient-perceived serious visit note errors: patient and family experiences and recommendations.

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Lam BD, Bourgeois FC, Dong ZJ, et al. J Am Med Inform Assoc. 2021;28:685-694.

Providing patients access to their medical records can improve patient engagement and error identification. A survey of patients and families found that about half of adult patients and pediatric families who perceived a serious mistake in their ambulatory care notes reported it, but identified several barriers to reporting (e.g. no clear reporting mechanism, lack of perceived support).

Delayed Breast Cancer Diagnosis: A False Sense of Security.

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December 23, 2020

After a breast mass was identified by a physician assistant during a routine visit, a 60-year-old woman received a diagnostic mammogram and ultrasound. The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably benign” findings. When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred for a biopsy.

Delayed Management of Necrotizing Soft Tissue Infection – Who does the Patient Belong To?

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April 29, 2020

A 52-year old women presented to the emergency department with a necrotizing soft tissue infection (necrotizing fasciitis) after undergoing cosmetic abdominoplasty (‘tummy tuck’) elsewhere. A lack of communication and disputes between the Emergency Medicine, Emergency General Surgery and Plastic Surgery teams about what service was responsible for the patient’s care led to delays in treatment. These delays allowed the infection to progress, ultimately requiring excision of a large area of skin and soft tissue.

"Do You Want Everything Done?": Clarifying Code Status

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December 18, 2019

A 63-year-old woman with hematemesis was admitted by a 2nd year medical resident for an endoscopy. The resident did not spend adequate time discussing her code status and subsequently, made a series of errors that failed to honor the patient’s preferences and could have resulted in an adverse outcome for this relatively healthy woman.

Lack of association between intraoperative handoff of care and postoperative complications: a retrospective observational study.

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O'Reilly-Shah VN, Melanson VG, Sullivan CL, et al. BMC Anesthesiol. 2019;19:182.

Utilizing American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) data, the authors looked at the effects of intraoperative handoffs involving anesthesia personnel in two hospitals. Initial findings of higher rates of adverse outcomes were no longer statistically significant when confounding variables were added to the analysis.

Pharmacist linkage in care transitions: from academic medical center to community.

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Bloodworth LS, Malinowski SS, Lirette ST, et al. Journal of the American Pharmacists Association: JAPhA. 2019;59:896-904.

Medication reconciliation is one potential strategy for preventing adverse events and readmissions. This study examined a pharmacist-led intervention involving collaborations with inpatient and community-based pharmacists to provide pre-discharge and 30-day medication reconciliation. There were indications that this type of intervention can reduce readmission rates, but further investigation in larger populations is necessary.

Discrepant advanced directives and code status orders: a preventable medical error.

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Meisenberg B, Zaidi S, Franks L, et al. J Hosp Med. 2019;14:716-718.

Advanced Directives (AD) and Physician Orders for Life-Sustaining Therapy (POLST) are intended to improve end-of-life care by ensuring that patient's wishes are honored by health care providers. This perspective presents two cases in which preventable errors allowed for the use of unwanted life-sustaining therapies. Root cause analyses for these cases found that haste, inadequate communication, EMR discrepancies, knowledge deficits contributed to these errors.

Patient Safety 101

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September 7, 2019

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.

Ensuring effective care transition communication: implementation of an electronic medical record-based tool for improved cancer treatment handoffs between clinic and infusion nurses.

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Pandya C, Clarke T, Scarsella E, et al. J Oncol Pract. 2019;15:e480-e489.

Care transitions and handoffs represent a vulnerable time for patients, as failure to communicate important clinical information may occur with the potential for harm. In this pre–post study, researchers found that implementation of an electronic health record tool designed to improve the handoff between oncology clinic and infusion nurses was associated with a reduction in medication errors, shorter average patient waiting time, and better communication between nurses.

Ambulatory safety nets to reduce missed and delayed diagnoses of cancer.

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Emani S, Sequist TD, Lacson R, et al. Jt Comm J Qual Patient Saf. 2019;45:552-557.

Health care systems struggle to ensure patients with precancerous colon and lung lesions receive appropriate follow-up. This academic center hired navigators who effectively increased the proportion of patients who completed recommended diagnostic testing for colon polyps and lung nodules. A WebM&M commentary described how patients with lung nodules are at risk for both overtreatment and undertreatment.

Renal Failure Due to Benign Prostatic Hyperplasia

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August 10, 2019

Referred to urology for a 5-year history of progressive urinary frequency, nocturnal urination, and difficulty initiating a stream, a man had been reluctant to seek care for his symptoms because his father had a "miserable" experience with treatment for the same condition. A physician assistant saw him at that first visit and ordered a PSA test (despite the patient's expressed views against PSA testing) and cystoscopy (without explaining why it was needed), and urged the patient to self-catheterize (without any instructions on how to do so).

The MedSafer Study: a controlled trial of an electronic decision support tool for deprescribing in acute care.

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McDonald EG, Wu PE, Rashidi B, et al. J Am Geriatr Soc. 2019;67:1843-1850.

This pre–post study compared patients who received medication reconciliation that was usual care at the time of hospital discharge to patients in the intervention arm who had decision support for deprescribing. Although the intervention did lead to more discontinuation of potentially inappropriate medications, there was no difference in adverse drug events between groups. The authors suggest larger studies to elucidate the potential to address medication safety using deprescribing decision support.

An opportunity to engage obstetrics and gynecology patients through shared visit notes.

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Herlihy M, Harcourt K, Fossa A, et al. Obstet Gynecol. 2019;134:128-137.

Prior research has shown that when patients have access to clinicians' notes, they may identify relevant safety concerns. In this study, 9550 obstetrics and gynecology patients were provided with access to their outpatient visit documentation. Almost 70% of eligible patients read one or more notes during the study period, but only 3.2% shared feedback through 232 electronic reports. Of patients who provided feedback, 27% identified errors in the documentation; provider reviewers determined that 75% of these could impact care.

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