Coffey M, Marino M, Lyren A, et al. JAMA Pediatr. 2022;Epub Jul 25.
The Partnership for Patients (P4P) program launched hospital engagement networks (HEN) in 2011 to reduce hospital-acquired harms. This study reports on the outcomes of eight conditions from one HEN, Children's Hospitals' Solutions for Patient Safety (SPS). While the results do show a reduction in harms, the authors state earlier claims of improvement may have been overstated due to failure to not adjust for secular improvements. The co-director of Partnership for Patients, Dr. Paul McGann, was interviewed in 2016 for a PSNet perspective.
Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:B2-B10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.
Samal L, Khasnabish S, Foskett C, et al. J Patient Saf. 2022;Epub Jul 21.
Adverse events can be identified through multiple methods, including trigger tools and voluntary reporting systems. In this comparison study, the Global Trigger Tool identified 79 AE in 88 oncology patients, compared to 21 in the voluntary reporting system; only two AE were identified by both. Results indicate multiple sources should be used to detect AE.
de Kraker MEA, Tartari E, Tomczyk S, et al. Lancet Infect Dis. 2022;22:835-844.
Hand hygiene is known to be a critical part of effective infection prevention and control. This study examined the level of hand hygiene implementation using the WHO Hand Hygiene Self-Assessment Framework global survey and its drivers. There were 3,206 organizations from 90 different countries that responded. Over half of the participants indicated they had intermediate hand hygiene implementation, particularly those with higher county income levels and facility funding. Implementation of alcohol-based hand rub stations was an important system change associated with improved scores.
Eldridge N, Wang Y, Metersky M, et al. JAMA. 2022;328:173.
Improving patient safety in hospitals is a longstanding national priority. Using longitudinal Medicare data from 2010 to 2019, this study identified a significant decrease in the rates of adverse events (e.g., adverse drug events, hospital-acquired infections, postoperative adverse events, hospital-acquired pressure ulcers, falls) over time among patients hospitalized for four common conditions – acute myocardial infarction, heart failure, pneumonia, and surgical procedures.
Halvorson EE, Thurtle DP, Easter A, et al. Acad Pediatr. 2022;22:747-753.
Previous research has identified an association between patient weight and certain adverse events and patient safety threats, such as medication dosing errors and airway management. After analyzing data for pediatric patients discharged from a single children’s hospital, researchers in this study did not identify an association between patient body mass index (BMI) and the rate, severity, or preventability of adverse events.
Hemmelgarn C, Hatlie MJ, Sheridan S, et al. J Patient Saf Risk Manage. 2022;27:56-58.
This commentary, authored by patients and families who have experienced medical errors, argues current patient safety efforts in the United States lack urgency and commitment, even as the World Health Organization is increasing its efforts. They call on policy makers and safety agencies to collaborate with the Patients for Patient Safety US organization to move improvement efforts forward.
Many interventions targeting healthcare-acquired condition reduction and prevention target a single condition, rather than the risks of multiple conditions. This proof-of-concept study discusses clinician feedback on a proposed dashboard to enhance clinicians’ management combining the risks of multiple conditions (catheter-associated urinary tract infections, pressure injuries, and falls).
Howell EA, Sofaer S, Balbierz A, et al. Obstet Gynecol. 2022;139:1061-1069.
Health equity in maternal safety is a major patient safety goal. Researchers interviewed health care professionals, including frontline nurses and physicians, chief medical officers, and quality and safety officers, from high- and low-performing hospitals. Six themes emerged differentiating high and low performers: 1) senior leadership involved in day-to-day quality activities and dedicated to quality improvement, 2) a strong focus on standards and standardized care, 3) strong nurse-physician communication and teamwork, 4) adequate physician and nurse staffing and supervision, 5) sharing of performance data with nurses and other frontline clinicians, and 6) explicit awareness that racial and ethnic disparities exist and that racism and bias in the hospital can lead to differential treatment. PSNet offers a Patient Safety Primer and Curated Library on maternal safety.
Acute care facilities in Pennsylvania are required to report all Incidents and Serious Events to the state’s Patient Safety Authority. This study updates the 2020 report. Similar to prior reports, Error Related to Procedure/Treatment/Test remained the most commonly reported events, followed by Medication Error, Complication of Procedure/Treatment/Test, and Fall.
Khan A, Parente V, Baird JD, et al. JAMA Pediatr. 2022;176:776-786.
Parent or caregiver limited English proficiency (LPE) has been associated with increased risk of their children experiencing adverse events. In this study, limited English proficiency was associated with lower odds of speaking up or asking questions when something does not appear right with their child’s care. Recommendations for improving communication with limited English proficiency patients and families are presented.
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.
Buetti N, Marschall J, Drees M, et al. Infect Control Hosp Epidemiol. 2022;43:553-569.
Central line-associated bloodstream infections (CLABSI) are a target of safety improvement initiatives, as they are common and harmful. This guideline provides an update on recommended steps for organizations to support the implementation of CLASBI reduction efforts.
Massart N, Mansour A, Ross JT, et al. J Thorac Cardiovasc Surg. 2022;163:2131-2140.e3.
Surgical site infections and other postoperative healthcare-acquired infections (HAIs) can lead to significant patient morbidity and mortality. This retrospective study examined the relationship between HAIs after cardiac surgery and postoperative inpatient mortality. Among 8,853 patients undergoing cardiac surgery in one academic hospital in France, 4.2% developed an HAI after surgery. When patients developing an HAI were matched with patients who did not, the inpatient mortality rate was significantly greater among patients with HAIs (15.4% vs. 5.7%).
Weaver MD, Landrigan CP, Sullivan JP, et al. BMJ Qual Saf. 2022;Epub May 10.
In 2011, the Accreditation Council for Graduate Medical Education (ACGME) introduced a 16-hour shift limit for first-year residents. Recent studies found that these duty hour requirements did not yield significant differences in patient outcomes and the ACGME eliminated the shift limit for first-year residents in 2017. To assess the impact of work-hour limits on medical errors, this study prospectively followed two cohorts of resident physicians matched into US residency programs before (2002-2007) and after (2014-2016) the introduction of the work-hour limits. After adjustment for potential confounders, the work-hour limit was associated with decreased risk of resident-reported significant medical errors (32% risk reduction), reported preventable adverse events (34% risk reduction), and reported medical errors resulting in patient death (63% risk reduction).
The AHRQ Patient Safety Indicators (PSI) capture the quality and safety in inpatient care and identify potential complications. This study compares the incidence of PSI-12 (perioperative venous thromboembolism (VTE)) in patients with and without acute COVID-19 infection. Patients with acute COVID-19 infection were at increased risk for meeting the criteria for PSI-12, despite receiving appropriate care. The researchers suggest taking this into consideration and updating PSIs, as appropriate.
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.
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.
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.
Tan J, Krishnan S, Vacanti JC, et al. J Healthc Risk Manag. 2022;42:9-14.
Inpatient falls are a common patient safety event and can have serious consequences. This study used hospital safety reporting system data to characterize falls in perioperative settings. Falls represented 1% of all safety reports between 2014 and 2020 and most commonly involved falls from a bed or stretcher. The author suggests strategies to identify patients at high risk for falls, improve fall-related training for healthcare personnel, and optimize equipment design in perioperative areas to prevent falls.
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