The PSNet Collection

Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.

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Woods-Hill CZ, Colantuoni EA, Koontz DW, et al. JAMA Pediatr. 2022;Epub May 2.

Stewardship interventions seek to optimize use of healthcare services, such as diagnostic tests or antibiotics. This article reports findings from a 14-site multidisciplinary collaborative evaluating pediatric intensive care unit (PICU) blood culture practices before and after implementation of a diagnostic stewardship intervention. Researchers found that rates of blood cultures, broad-spectrum antibiotic use, and central line-associated blood stream infections (CLABSI) were reduced postintervention.

Exploring system features of primary care practices that promote better providers' clinical work satisfaction: a qualitative comparative analysis.

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Liu L, Chien AT, Singer SJ. Health Care Manage Rev. 2022;Epub Apr 30.

Work conditions can impact clinician satisfaction and the quality and safety of the care they provide. This study sought to identify the combination of systems features (team dynamics, provider-perceived safety culture, patient care coordination) that positively impact work satisfaction in primary care practices. Results showed a strong culture of safety combined with more effective team dynamics were sufficient to lead to improved work satisfaction.

Differences in hospitals' workplace violence incident reporting practices: a mixed methods study.

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Odes R, Chapman SM, Ackerman SL, et al. Policy Polit Nurs Pract. 2022;23:98-108.

Violence towards healthcare workers can result in harm for staff and patients. This article describes data collected during the first three years of a new statewide incident reporting system, California’s Workplace Violent Incident Reporting System (WVIRS) for Hospitals. Over the three-year period, hospitals reported between 0 and 6 incidents per staffed bed but qualitative analyses revealed variable reporting procedures among hospitals.

AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI: Final Report.

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Molefe A, Hung L, Hayes K, et al. Rockville MD: Agency for healthcare Research and Quality; 2022. AHRQ Publication No. 17(22)-0019.

Central line associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) are a persistent challenge for health care safety. This report shares the results of a 6-cohort initiative to reduce CLABSI and/or CAUTI infection rates in adult critical care. Recommendations for collaborative implementation success are included.

Multispecialty physician online survey reveals that burnout related to adverse event involvement may be mitigated by peer support.

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Gupta K, Rivadeneira NA, Lisker S, et al. J Patient Saf. 2022;Epub Apr 27.

Strategies to reduce clinician burnout related to adverse events are critically needed. Physicians in the United States were surveyed on their experiences with adverse events to identify facilitators and barriers to reducing burnout. A common facilitator was peer support, and barriers included shame and a punitive work environment.

Patient safety in home care: a multicenter cross-sectional study about medication errors and medication management of nurses.

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Strube‐Lahmann S, Müller‐Werdan U, Klingelhöfer‐Noe J, et al. Pharmacol Res Perspect. 2022;10:e00953.

Patients receiving home care services are vulnerable to medication errors. Based on survey feedback from 485 home care nurses in Germany, this study found that regular medication training and use of quality assurance principles (i.e., double checking) can decrease the incidence of medication errors in home care settings.

Observational evidence of the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients.

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Savva G, Papastavrou E, Charalambous A, et al. Sr Care Pharm. 2022;37:200-209.

Polypharmacy is an established problem among older adult patients and can lead to medication errors and adverse events. This observational study concluded that polypharmacy was common among adult patients (ages 21 and older) at one tertiary hospital, with almost half of inpatients prescribed more than 9 drugs during their hospitalization. Findings indicate that medication administration errors increase as the number of prescribed drugs increased.

Part 2 of the 9th Annual Communication, Apology, and Resolution (CARe) Forum.

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Betsy Lehman Center for Patient Safety. June 2, 2022, 9:30 AM-12:00 PM (eastern).

Communication and resolution programs are a promising strategy for successful management of relationships and actions after medical error occurrence. This session will explore elements of effective discussions after an adverse event through case simulation and dialogue.

Nursing surveillance: a concept analysis

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Halverson CC, Scott Tilley D. Nurs Forum. 2022;57:454-460.

Nursing surveillance is an intervention for maintaining patient safety and preventing patient deterioration. This review builds on the earlier nursing surveillance concept to reflect technological advancements, such as early warning systems, since the intervention was first proposed. Attributes (e.g., systematic processes and coordinated communication) and antecedents (e.g., sufficient nurse education and staffing) associated with nursing surveillance are described, along with a presentation of cases to illustrate the concept.

Assessing quality of older persons' emergency transitions between long-term and acute care settings: a proof-of-concept study.

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Tate K, McLane P, Reid C, et al. BMJ Open Qual. 2022;11:e001639.

Older adults are vulnerable to patient safety events during care transitions. The Older Persons’ Transitions in Care (OPTIC) study prospectively tracked long-term care residents’ transitions and applied the IOM’s quality of care domains to develop 49 measures for quality of care for the transition process (e.g., safety, timeliness, efficiency, effectiveness, and patient-centered care) between long-term care and emergency department settings.

Understanding the factors influencing implementation of a new national patient safety policy in England: lessons from 'Learning from Deaths'.

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Lalani M, Morgan S, Basu A, et al. J Health Serv Res Policy. 2022;Epub May 6.

Autopsies following unexpected deaths can provide valuable insights and learning opportunities for improving patient safety. In 2017, the National Health Service (NHS) implemented “Learning from Deaths” (LfD) to report, learn from, and avoid potentially preventable deaths. Through interviews with policy makers, managers, and senior clinicians responsible for implementing the policy, this study reports on how contextual factors influenced implementation of the LfD policy.

Applying requisite imagination to safeguard electronic health record transitions.

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Sittig DF, Lakhani P, Singh H. J Am Med Inform Assoc. 2022;29:1014-1018.

Transitions from one electronic health record (EHR) system to another can increase the risk of patient safety events. Using the principles of requisite imagination, this article outlines six recommendations for safe EHR transitions through proactive approaches, process improvement and support for healthcare workers.

Survey shows room for improvement with three new best practices for hospitals.

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Medication Safety Alert! Acute care edition. May 5, 2022;27(9):1-5.

Practice changes take time to be fully incorporated into daily work. This article shares survey results examining how hospitals implement best practices to enhance the safe use of oxytocin, improve vaccine administration through bar coding, and deploy multifaceted strategies to reduce high-alert medication errors. Gaps in uptake were reviewed and recommendations for improvement shared.

Human factors analysis of latent safety threats in a pediatric critical care unit.

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Trbovich PL, Tomasi JN, Kolodzey L, et al. Pediatr Crit Care Med. 2022;23:151-159.

Intensive care units (ICU) are high-risk environments. Based on direct observations, these researchers identified 226 latent safety threats affecting routine care activities in pediatric ICUs. Findings indicate that threats persist regardless of whether individuals comply with or deviate from policies and protocols, suggesting the need for targeted interventions beyond reinforcing compliance.

In Conversation With... Remle P. Crowe, PhD

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May 16, 2022

Remle Crowe, PhD, NREMT, is the Director of Clinical and Operational Research at ESO. In her professional role, she provides strategic direction for the research mission of the organization, including oversight of a warehouse research data set of de-identified records (the ESO Data Collaborative). We spoke with her about how data is being used in the prehospital setting to improve patient safety.

Identifying Safety Events in the Prehospital Setting

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May 16, 2022

This piece focuses on measuring and monitoring patient safety in the prehospital setting.

Management of Cardiac Arrest in Unconventional Locations.

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May 16, 2022

This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms.

Check Twice, Transport Once

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May 16, 2022

This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.

Anti-black racism as a chronic condition.

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Sederstrom N, Lasege T. Hastings Cent Rep. 2022;52:s24-s29.

Racial bias and systemic racism in healthcare are increasingly seen as critical patient safety issues. This commentary discusses the relationship between medical ethics and racism in healthcare institutions, using examples such as racial biases in clinical tools and algorithms, the effect of racial bias on diagnosis and diagnostic error, and how excess disease burden can be viewed as proxy for racism.

Fast tracking in cardiac surgery: is it safe?

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MacLeod JB, D’Souza K, Aguiar C, et al. J Cardiothorac Surg. 2022;17:69.

Post-operative complications can lead to increased length of hospital stay, cost, and resource utilization. This retrospective study compared “fast track” patients (patients extubated and transferred from ICU to a step-down unit the same day as their procedure) and patients who were not fast tracked. Results showed fast track pathways led to a reduction in ICU and overall hospital length of stay and similar post-operative outcomes.

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