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.
Wang Y, Eldridge N, Metersky ML, et al. JAMA Netw Open. 2022;5:e2214586.
Hospital readmission rates are an important indicator of patient safety. This cross-sectional study examined whether patients admitted to hospitals with high readmission rates also had higher risks of in-hospital adverse events. Based on a sample of over 46,000 Medicare patients with pneumonia discharged between July 2010 and December 2019 and linked to Medicare adverse event data, researchers found that patients admitted to hospitals with high all-cause readmission rates were more likely to experience an adverse event during their admission.
de Loizaga SR, Clarke-Myers K, R Khoury P, et al. J Patient Exp. 2022;9:237437352211026.
Parents have reported the importance of being involved in discussions with clinicians following adverse events involving their children. This study asked parents and physicians about their perspectives on inclusion of parents in morbidity and mortality (M&M) reviews. Similar to earlier studies, parents wished to be involved, while physicians were concerned that parent involvement would draw attention away from the overall purpose (e.g., quality improvement) of M&M conferences.
Milliren CE, Bailey G, Graham DA, et al. J Patient Saf. 2022;18:e741-e746.
The Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) use a variety of quality indicators to measure and rank hospital performance. In this study, researchers analyzed the variance between AHRQ pediatric quality indicators and CMS hospital-acquired condition indicators and evaluated the use of alternative composite scores. The researchers identified substantial within-hospital variation across the indicators and could not identify a single composite measure capable of capturing all of the variance observed across the broad range of outcomes. The authors call for additional research to identify meaningful approaches to performance ranking for children’s hospitals.
Hunt J. London, UK: Swift Press; 2022. ISBN: 9781800751224.
The National Health Service (NHS) has been a leader in patient safety for over 20 years, and yet NHS patients still experience harm. This book shares leadership insights from former NHS Health Secretary Jeremy Hunt intended to help the institution reach a place where zero patient harm will occur. The book discusses primary causes of patient harm, the challenge of organizational culture, solutions supporting improvement, and implementation strategies.
Barnard C, Chung JW, Flaherty V, et al. Jt Comm J Qual Patient Saf. 2022;Epub Apr 28.
Organizations such as The Joint Commission and the Leapfrog Group require participating healthcare organizations to evaluate their patient safety culture, but surveys can represent a time burden on staff. An Illinois health system aimed to lessen this burden on staff by creating a shorter, revised survey. The final survey consisted of five questions with comparable measurement properties of the original 17-question survey; however, the authors caution the shorter survey will yield less detail than the longer version.
Powell ES, Bond WF, Barker LT, et al. J Patient Saf. 2022;18:302-309.
Telehealth is increasingly used to connect rural hospitals with specialists in other areas and can improve patient outcomes. This study found that in situ simulation training in rural emergency departments resulted in small increases in the use of telemedicine for patients presenting with sepsis and led to improvements in sepsis process care outcomes.
Davy A, Borycki EM. Stud Health Technol Inform. 2022;290:438-441.
Dashboards provide a way to display patient safety data (e.g., medication safety) in real time. This narrative review and SWOT (strengths, weaknesses, opportunities, threats) of existing patient safety dashboards can form the basis for developing future dashboards.
Cedillo G, George MC, Deshpande R, et al. Addict Sci Clin Pract. 2022;17:28.
In 2016, the Centers for Disease Control (CDC) issued an opioid prescribing guideline intended to reverse the increasing death rate from opioid overdoses. This study describes the development, implementation, and effect of a safe prescribing strategy (TOWER) in an HIV-focused primary care setting. Providers using TOWER were more adherent to the CDC guidelines, with no worsening patient-reported outcome measures.
This annual Patient Safety Reporting Program (PSRP) publication provides data and analysis of adverse events voluntarily reported to the Oregon Patient Safety Commission. The review of 2021 data discusses the impact of the state adverse event reporting program and upcoming initiative to examine how organizational safety effort prioritization affects care in Oregon.
Baim-Lance A, Ferreira KB, Cohen HJ, et al. J Gen Intern Med. 2022;Epub May 17.
When serious adverse events such as death are reported, they are typically associated with poor patient safety. In some fields of care, however, such as palliative care, deaths are expected and not necessarily an indicator of poor quality. This commentary describes how serious and non-serious adverse events (SAEs/AEs) are currently defined and reported, the associated challenges, and proposes a new approach to reporting SAE/AE in clinical trials. A decision-tree to determine SAE/AE reporting based on the new proposed approach is presented.
Mortensen M, Naustdal KI, Uibu E, et al. BMJ Open Qual. 2022;11:e001751.
A 2011 systematic review identified nine tools to assess patient safety competence in nurses. This review identified multiple instruments released since that review; the most frequently used was the Health Professional Education in Patient Safety Survey (H-PEPSS). The authors suggest future research should consider including ethics in patient safety and responsiveness to change over time.
Ong N, Mimmo L, Barnett D, et al. Dev Med Child Neurol. 2022;Epub May 16.
Patients with intellectual disabilities may be at higher risk for patient safety events. In this study, researchers qualitatively analyzed hospital incident reporting data and identified incidents categories disproportionately experienced by children with intellectual disabilities. These incident categories included medication-intravenous fluid issues, communication failures, clinical deterioration, and care issues identified by parents.
Abdelmalak BB, Adhami T, Simmons W, et al. Anesth Analg. 2022;Epub May 12.
A 2009 CMS Condition of Participation (CoP) requires that a director of anesthesia services assume overall responsibility for anesthesia administered in the hospital, including procedural sedation provided by nonanesthesiologists. This article reviews the CoP as it relates to procedural sedation, lays out a framework for implementing this role, and describes challenges of implementation in a large health system.
Hindmarsh J, Holden K. Int J Med Inform. 2022;163:104777.
Computerized provider order entry has become standard practice for most medication ordering. This article reports on the safety and efficiency of ordering mixed-drug infusions before and after implementation of electronic prescribing. After implementation, rates of prescription errors, time to process discharge orders, and time between prescription and administration all decreased.
Salema N-E, Bell BG, Marsden K, et al. BJGP Open. 2022;Epub May 6.
Medication prescribing errors are common, particularly during medical training. This retrospective review of prescriptions from ten general practitioners in training in the United Kingdom identified a high rate of prescribing errors (8.9% of prescriptions reviewed) and suboptimal prescribing (35%).
Phadke NA, Wickner PG, Wang L, et al. J Allergy Clin Immunol Pract. 2022;Epub Apr 7.
Patient exposure to allergens healthcare settings, such as latex or certain medications, can lead to adverse outcomes. Based on data from an incident reporting system, researchers in this study developed a system for classifying allergy-related safety events. Classification categories include: (1) incomplete or inaccurate EHR documentation, (2) human factors, such as overridden allergy alerts, (3) alert limitation or malfunction, (4) data exchange and interoperability failures, and (5) issues with EHR system default options. This classification system can be used to support improvements at the individual, team, and systems levels.
Butler AM, Brown DS, Durkin MJ, et al. JAMA Netw Open. 2022;5:e2214153.
Inappropriately prescribing antibiotics for non-bacterial infections remains common in outpatient settings despite the associated risks. This analysis of antibiotics prescribed to more than 2.8 million children showed more than 30% of children with bacterial infection, and 4%-70% of children with viral infection were inappropriately prescribed antibiotics. Inappropriate prescribing led to increased risk of adverse drug events (e.g., allergic reaction) and increased health expenditures in the following 30 days.
Graber ML, Holmboe ES, Stanley J, et al. Diagnosis (Berl). 2022;9:166-175.
In 2019, a consensus group identified twelve competencies to improve diagnostic education. This article details next steps for incorporating competencies into interprofessional health education: 1) Developing a shared, common language for diagnosis, 2) developing the necessary content, 3) developing assessment tools, 4) promoting faculty development, and 5) spreading awareness of the need to improve education in regard to diagnosis.
Checklists are used to improve patient outcomes in a wide variety of clinical settings and processes, such as childbirth, surgery, and diagnosis. This review applied the Systems Engineering Initiative for Patient Safety 2.0 (SEIPS 2.0) human factors framework to 25 diagnostic checklists. Checklists were characterized within the three primary components (work systems, processes, and outcomes) and subcomponents. Checklists addressing the Task subcomponent were associated with a reduction in diagnostic errors. Several subcomponents were not addressed (e.g. External Environment, Organization) and present an opportunity for future research.
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