Gupta K, Szymonifka J, Rivadeneira NA, et al. Jt Comm J Qual Patient Saf. 2022;Epub May 28.
Analysis of closed malpractice claims can be used to identify potential safety hazards in a variety of clinical settings. This analysis of closed emergency department malpractice claims indicates that diagnostic errors dominate, and clinical judgment and documentation categories continue to be associated with a higher likelihood of payout. Subcategories and contributing factors are also discussed.
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.
Combs CA, Goffman D, Pettker CM. Am J Obstet Gynecol. 2022;226:B2-B9.
Readmission reduction as an improvement measure has been found to be problematic as a maternal safety outcome. This statement shares concerns regarding incentivizing hospitalization reductions after birth and explores the potential for patient harm due to pressures to reduce readmissions when needed.
Morsø L, Birkeland S, Walløe S, et al. Jt Comm J Qual Patient Saf. 2022;48:271-279.
Patient complaints can provide insights into safety threats and system weaknesses. This study used the healthcare complaints analysis tool (HCAT) to identify and categorize safety problems in emergency care. Most problems arose during examination/diagnosis and frequently resulted in diagnostic errors or errors of omission.
Lin MP, Vargas-Torres C, Shin-Kim J, et al. Am J Emerg Med. 2022;53:135-139.
Drug shortages can result in patient harm, such as dosing errors from a medication substitution. In this study, 28 of the 30 most frequently used medications in the emergency department experienced shortages between 2006 and 2019. The most common reasons for shortages were manufacturing delays and increased demand. The COVID-19 pandemic exacerbated pre-existing drug shortages.
Zheng MY, Lui H, Patino G, et al. J Patient Saf. 2022;18:e401-e406.
California law requires adverse events that led to serious injury or death because of hospital noncompliance to be reported to the state licensing agency. These events are referred to as “immediate jeopardy.” Using publicly available data, this study analyzed all immediate jeopardy cases between 2007 and 2017. Of the 385 immediate jeopardy cases, 36.6% led to patient death, and the most common category was surgical.
Petrovic M, Nicholls J, Siassakos D. Best Pract Res Clin Obstet Gynaecol. 2022;80:105-113.
Improving safe maternal care is an ongoing patient safety priority. This article outlines training strategies for providing safe obstetric care and improving communication among providers and patients.
Fan B, Pardo J, Yu-Moe CW, et al. Ann Surg Oncol. 2021;28:8109-8115.
While prior research has described malpractice cases related to breast cancer diagnosis and treatment, this study sought to identify errors specifically related to breast cancer surgical procedures. Plastic surgeons were the most commonly named provider type (64%), error in surgical treatment was the most common allegation (87%), and infection, cosmetic injury, emotional trauma, foreign body, and nosocomial infection were the top 5 injury descriptions.
Trost SL, Beauregard JL, Smoots AN, et al. Health Aff (Millwood). 2021;40:1551-1559.
Missed diagnosis of mental health conditions can lead to serious adverse outcomes. Researchers evaluated data from 2008 to 2017 from 14 state Maternal Mortality Review Committees and found that 11% of pregnancy-related deaths were due to mental health conditions. A substantial proportion of people with a pregnancy-related mental health cause of death had a history of depression or past/current substance use. Researchers conclude that addressing gaps maternal mental health care is essential to improving maternal safety.
Schaffer AC, Babayan A, Einbinder JS, et al. Obstet Gynecol. 2021;138:246-252.
Adverse events in obstetrics threaten the safety of both maternal and infant patients. This study identified a significant reduction in malpractice claims among obstetrician-gynecologists after participation in simulation training focused on team training and crisis management.
Arntson E, Dimick JB, Nuliyalu U, et al. Ann Surg. 2021;274:e301-e307.
Hospital-acquired conditions (HACs) are thought to be preventable, and the Centers for Medicare & Medicaid Services (CMS) reduce payments to hospitals with the highest rates of these conditions through its Hospital-Acquired Condition Reduction Program (HACRP). This study evaluated surgical HACs at three timepoints: before Affordable Care Act (ACA) implementation, after ACA implementation, and after HACRP. While the number of HACs continued to decline after implementation of HACRP, it did not affect 30-day mortality.
Chua K-P, Brummett CM, Conti RM, et al. Pediatrics. 2021;148:e2021051539.
Despite public policies and guidelines to reduce opioid prescribing, providers continue to overprescribe these medications to children, adolescents, and young adults. In this analysis of US retail pharmacy data, 3.5% of US children and young adults were dispensed at least one opioid prescription; nearly half of those included at least one factor indicating they were high risk. Consistent with prior research, dentists and surgeons were the most frequent prescribers, writing 61% of all opiate prescriptions.
Douglas RN, Stephens LS, Posner KL, et al. Br J Anaesth. 2021;127:470-478.
Effective communication among providers helps ensure patient safety. Through analysis of perioperative malpractice claims using the Anesthesia Closed Claims Project database, researchers found that communication failures contributed to 43% of total claims, with the majority between the anesthesiologist/anesthesia team and the surgeon/surgery team. Methods to improve perioperative communication are discussed.
Marang-van de Mheen PJ, Vincent CA. BMJ Qual Saf. 2021;30:525-528.
Research has shown that patients admitted to the hospital on the weekend may experience worse outcomes compared to those admitted on weekdays (the ‘weekend effect’). This editorial highlights the challenges to empirically evaluate the underlying mechanisms contributing to the weekend effect. The authors propose viewing the weekend effect as a proxy for staffing levels and the influence of other factors influencing outcomes for patients admitted on weekends, such as patient acuity, clinician skill-mix and access to diagnostic tests or other ancillary services.
Misdiagnosis of child abuse has far-reaching implications. This commentary discusses the ethical tensions faced by pediatric radiologists of both over- and under-diagnosing child abuse. The author suggests ways that physicians and professional societies can partner with legal advocates to create a more balanced pool of experts to alleviate perceptions of bias and acknowledge harms of misdiagnosed child abuse.
Synan LT, Eid MA, Lamb CR, et al. Surgery. 2021;170:764-768.
This study compared unsolicited hospital reviews posted online by patients with Hospital Compare patient satisfaction and postsurgical safety indicators. While there was variation in consumer ratings between platforms, unstructured consumer reviews were generally correlated with Hospital Compare patient satisfaction scores; consumer platforms were not consistently correlated with postsurgical patient safety indicators.
Kurteva S, Abrahamowicz M, Gomes T, et al. JAMA Netw Open. 2021;4:e218782.
Using administrative data and patient interviews, this study sought to estimate opioid-related adverse events in adults discharged from one Canadian hospital. Among patients who filled at least one opioid prescription in the 90 days following hospital discharge, approximately 16% experienced an opioid-related emergency department visit, hospital readmission, or death. Longer duration of use and higher daily dose were associated with increased risk of adverse events. Results from this study can inform policies and strategies to limit opioid prescription dose and duration.
Cohen AJ, Lui H, Zheng M, et al. JAMA Netw Open. 2021;4:e217058.
While rare, surgical never events can have tragic consequences for patients including permanent harm and death. This study analyzed 142 surgical never events reported to the California Department of Public Health. Retained foreign objects were the most commonly reported never event (66.2%), followed by wrong site or wrong patient (15.5%), and surgical burns (7.7%). Recommended strategies to reduce and prevent never events include proper use of intraoperative checklists.
Maternal death or harm is disproportionately experienced by women of color in the United States. This perspective discusses legislative efforts to address discrepancies affecting the safety of this patient population. The author reviews weaknesses of this approach which include a lack of emphasis on state-level analysis of the problem to address system-level contributors to the problem.
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