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.

What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency department: an analysis of serious adverse event reports.

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Baartmans MC, Hooftman J, Zwaan L, et al. J Patient Saf. 2022;Epub Apr 21.

Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.

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.

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.

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.

Society for Maternal-Fetal Medicine Special Statement: A critique of postpartum readmission rate as a quality metric.

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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.

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.

The effects of leadership curricula with and without implicit bias training on graduate medical education: a multicenter randomized trial.

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Hansen M, Harrod T, Bahr N, et al. Acad Med. 2022;97:696-703.

Strong physician leadership during clinical crisis can help improve patient outcomes. In this randomized controlled trial, obstetrics-gynecology and emergency medicine residents participated in one of three study arms using high-fidelity mannequins. One study arm received a bespoke leadership curriculum, one received a modified version TeamSTEPPS curriculum, and the third received no leadership training. Participants in both curriculum arms improved leadership scores from “average” before the training to “good” following the training and continuing to six months. The control arm remained unchanged at “average” before and after.

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.

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.

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.

Clinical progress note: situation awareness for clinical deterioration in hospitalized children.

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Sosa T, Galligan MM, Brady PW. J Hosp Med. 2022;17:199-202.

Situation awareness supports effective teamwork and safe care delivery. This commentary highlights the role of situation awareness in watching the condition of pediatric inpatients to reduce instances of unrecognized clinical deterioration. It features rapid response models enhanced by event review, psychological safety, and patient and family partnering as mechanisms improved through situation awareness.

Clinician distress and inappropriate antibiotic prescribing for acute respiratory tract infections: a retrospective cohort study.

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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.

Barriers and enablers to nurses' use of harm prevention strategies for older patients in hospital: a cross-sectional survey.

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Redley B, Taylor N, Hutchinson AM. J Adv Nurs. 2022;Epub Apr 22.

Nurses play a critical role in reducing preventable harm among inpatients. This cross-sectional survey of nurses working in general medicine wards identified both enabling factors (behavioral regulation, perceived capabilities, and environmental context/resources) and barriers (intentions, perceived consequences, optimism, and professional role) to implementing comprehensive harm prevention programs for older adult inpatients.

Communication patterns during routine patient care in a pediatric intensive care unit: the behavioral impact of in situ simulation.

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Ulmer FF, Lutz AM, Müller F, et al. J Patient Saf. 2022;18:e573-e579.

Closed-loop communication is essential to effective teamwork, particularly during complex or high-intensity clinical scenarios. This study found that participation in a one-day simulation team training for pediatric intensive care unit (PICU) nurses led to significant improvements in closed-loop communication in real-life clinical situations.

Compensation claims in Danish emergency care: identifying hot spots and blind spots in the quality of care.

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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.

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