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National Academies of Sciences, Engineering, and Medicine. Arnold and Mabel Beckman Center, Irvine, CA. July 21, 2022, 11:30 AM-6:30 PM (eastern).

The care of older adult patients can be complicated due to comorbidities and polypharmacy. This session will examine diagnostic challenges unique to the older adult population. The existing evidence base and research strategies for the future will be discussed.

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. 

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.

Lee EH, Pitts S, Pignataro S, et al. Clin Teach. 2022;19:71-78.
The inherent power imbalance between supervisors and new clinicians may inhibit new clinicians from asking questions or reporting mistakes. This lack of psychological safety can result in patient harm and restrict learning. This article provides strategies for healthcare educators and leaders to model and guide a safer organization. Three phases of the supervisor-learner relationship, along with suggested prompts, are provided.
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.

Cox C, Fritz Z. BMJ. 2022;377:e066720.

As more patients are gaining access to their electronic health records, including clinician notes, the language clinicians use can shape how patients feel about their health and healthcare provider. This commentary describes how some words and phrases routinely used in provider notes, such as “deny” or “non-compliant”, may inadvertently build distrust with the patient. The authors recommend medical students and providers reconsider their language to establish more trusting relationships with their patients.
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.
Brady KJS, Barlam TF, Trockel MT, et al. Jt Comm J Qual Patient Saf. 2022;48:287-297.
Inappropriate prescribing of antibiotics to treat viral illnesses is an ongoing patient safety threat. This study examined the association between clinician depression, anxiety, and burnout and inappropriate prescribing of antibiotics for acute respiratory tract infections (RTIs) in outpatient care. Depression and anxiety, but not burnout, were associated with increased adjusted odds of inappropriate prescribing for RTIs.

Chicago, IL: Harpo Productions, Smithsonian Channel: May 2022.

The COVID-19 pandemic revealed the impact of racial disparities and inequities on patient safety for patients of color. This film shares stories of families whose care was unsafe. The cases discussed highlight how missed and dismissed COVID symptoms and inattention to patient and family concerns due to bias reduces patient safety.
Ong N, Long JC, Weise J, et al. J Appl Res Intellect Disabil. 2022;35:675-690.
Children with intellectual disabilities can be at higher risk for patient safety events and poor-quality care. This systematic review and thematic analysis identified several themes (e.g., distress, communication, training, and education) underscoring healthcare staff experiences in providing care for pediatric patients with intellectual disabilities. The review found that healthcare staff feel they lack necessary skills to provide care for children with intellectual disabilities and have difficulties communicating effectively with both patients and their parents.

Institute for Safe Medication Practices and the Just Culture Company. May 6, 2022.

Organizational factors can contribute to the occurrence of patient safety events and how health systems respond to such events. This webinar highlighted lessons learned in the aftermath of a fatal medication error, and strategies to improve patient safety at the organizational level through system design and accountability.

JAMA. 2021-2022. 

Diagnostic excellence achievement is becoming a primary focus in health care. This article series covers diagnosis as it relates to the Institute of Medicine quality domains, clinical challenges, and priorities for improvement across the system.

Jagsi R, Griffith KA, Vicini F, et al for the Michigan Radiation Oncology Quality Consortium. JAMA OncolEpub 2022 Apr 21. 

Concordance of patient-reported symptoms and provider-documented symptoms is necessary for appropriate patient care and has clinical implications for research. This study compared patient-reported symptoms (pain, pruritus, edema, and fatigue) following radiotherapy for breast cancer with provider assessments. Underrecognition of at least one symptom occurred in more than 50% of patients. Underrecognition was more common in Black patients and those seen by male physicians. The authors suggest that interventions to improve communication between providers and patients may not only improve outcomes but also reduce racial disparities.
Madden C, Lydon S, Murphy AW, et al. Fam Pract. 2022;Epub Apr 20.
Patient complaints and patient-reported incidents can help identify safety issues. This study compared clinician perceptions and patients’ accounts regarding patient safety incidents and identified a significant difference in perceptions about incident severity. Patients’ accounts of incidents commonly described deficiencies related to communication, staff performance, compassion, and respect.

London UK: Patient Safety Learning: 2022.

Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financially. This report examines large system failures in the UK National Health Service to suggest actions that support learning and improvement. The publication highlights how public investigations, government reports, legal actions, and patient complaints can provide information to support the systems approach required to arrive at safe care.
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.
This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety. In addition, it covers safe practices when technologies are not available.
AORN J. 2022;115:454-457.
This position statement outlines recommendations from the Association of periOperative Registered Nurses on core components of safe perioperative nursing and its role in strengthening patient safety. Elements discussed include error reduction, leadership engagement, and safe working environment..
Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.

An 18-month-old girl presented to the Emergency Department (ED) after being attacked by a dog and sustaining multiple penetrating injuries to her head and neck. After multiple unsuccessful attempts to establish intravenous access, an intraosseous (IO) line was placed in the patient’s proximal left tibia to facilitate administration of fluids, blood products, vasopressors, and antibiotics.  In the operating room, peripheral intravenous (IV) access was eventually obtained after which intraoperative use of the IO line was restricted to a low-rate fluid infusion.