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Emergence of Application-based Healthcare

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August 5, 2022

This piece focuses on the emergence and use of digital applications (apps), app-based products and devices for healthcare, and the implications for patient safety.

In conversation with Francoise Marvel, MD

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August 5, 2022

Francoise A. Marvel, MD, is an assistant professor of medicine within the Division of Cardiology at Johns Hopkins Hospital, codirector of the Johns Hopkins Digital Health Innovation Lab, and the chief executive officer (CEO) and cofounder of Corrie Health. We spoke with her about the emergence of application-based tools used for healthcare and the patient safety issues surrounding the use of such tools.

When the water breaks.

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Jones LA. The Philadelphia Inquirer. July 17, 2022.

Racial disparities and inequities detract from safe maternal care. This feature article discusses the history of obstetric care in the United States and examines the roots of unsafe care for Black mothers that perpetuate in that community today.

Improving Diagnosis in Medicine Act of 2022.

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117th Congress 2d Session. June 21, 2022.

Strengthening diagnostic error research and training can lead to sustained diagnostic improvement. Expanding upon legislation introduced in 2020, the “Improving Diagnosis in Medicine Act of 2022” would establish research centers of diagnostic excellence, an interagency council on improving diagnosis in healthcare, and fellowship and training grants in diagnostic safety, as well as convene an expert panel on diagnostic error measurement and data collection and prioritize stakeholder engagement across all activities.

Independent Neurology Inquiry.

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Lockhart B, Mascie-Taylor H. Crown Copyright: London, England; June 2022. ISBN 9781912313631.

Misdiagnosis of neurological conditions, such as stroke, can lead to delays in treatment and patient morbidity and mortality. This report outlines findings from an inquiry into one misdiagnosis attributed to one neurologist in Ireland and discusses the leadership, system, process, and communication failures which permitted misdiagnoses to go unchecked.

Under the Skin. The Hidden Toll of Racism on American Lives and on the Health of our Nation.

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Villarosa L. New York, NT: Doubleday: 2022. ISBN 9780385544887.

Health inequities are receiving increased attention as a patient safety issue. This book examines the persistent problem of systemic racism on the health of Black patients. It summarizes the evidence on how racism affects health care and discusses strategies for improvement such as reducing gaps in implicit bias content in curriculum.

Harm Caused by Delays in Transferring Patients to the Right Place of Care.

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Farnborough, UK: Healthcare Safety Investigation Branch; June 2022.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This interim report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.

Antifatness in the surgical setting.

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Andreou A. Scientific American. May 26, 2022.

Negative comments and attitudes indicate a lack of professionalism that can affect patient care. This article shares concerns about surgeon biases toward patients who are overweight and calls for clinicians to recognize the problem and address it.

Nurse Vaught sentenced for deadly medical error.

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DePeau-Wilson M. MedPage Today. May 13, 2022.

Disciplinary actions against clinicians who err continue despite awareness efforts to inhibit them. This article summarizes reaction to the sentencing of a nurse in a high-profile medication error case. It discusses reverberations throughout healthcare that will affect patient safety efforts.

The Color of Care.

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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.

Final Report of the Ockenden Review.

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London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294.

Maternal and baby harm in healthcare is a sentinel event manifested by systemic failure. This report serves as the final conclusions of an investigation into 250 cases at a National Health System (NHS) trust. The authors share overarching system improvement suggestions and high-priority recommendations to initiate NHS maternity care improvement.

Woman works to end Black maternal health crisis after daughter dies after giving birth.

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Kindelan K. ABC News. April 14, 2022.

Maternal injury is a persistent challenge in the Black community. This article discusses the case of one mother whose discounted health concerns contributed to diagnostic delay and death. The piece shares social media tools to assist Black mothers in keeping themselves safe during pregnancy and after birth.

HEAR Her Concerns.

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National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health; Centers for Disease Control and Prevention.

Maternal harm during and after pregnancy is a sentinel event. This campaign encourages women, families, and health providers to identify and speak up with concerns about maternal care and act on them. The program seeks to inform the design of support systems and tool development that enhance maternal safety.

Will prosecuting medical errors lead to a culture of silence?

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Fiore K. MedPage Today. March 28, 2022.

Experts are concerned that convictions for medical error have the potential to limit dialogue on the front line about medical mistakes. This article summarizes discussions regarding the verdict to convict a nurse due to a workaround that resulted in a medication error and patient death.

Dying for Care.

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Stein L, Fraser J, Penzenstadler N et al. USA Today. March 10, 2022.

Nursing home residents, staff, and care processes were particularly vulnerable to COVID-19. This collection of resources examines data and documentation involving one nursing home chain to reveal systemic problems that contributed to failure. It shares family stories that illustrate how COVID affected care in long-term care environments.

Bias in mental health diagnosis gets in the way of treatment.

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Garb HN. Psyche. March 22, 2022.

A wide array of biases can affect clinical judgement and contribute to diagnostic error. This article discusses the impact of implicit biases, test inaccuracy, and data weaknesses in diagnosis of mental health conditions in both children and adults. The author provides recommendations for clinicians and researchers to reduce the impact of bias on diagnosis.

A widow’s mission to change NC dental sedation rules.

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Blythe A. NC Health News. March 10, 2022

Patient harm in dentistry is receiving increased attention and scrutiny. This story covers a medication incident and the lack of safety support that contributed to the death of a patient receiving oral surgery. It discusses the response of the patient’s family and their work to change regulations for dental sedation.

Maternity Pre-arrival Instructions by 999 Call Handlers.

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Farnborough, UK: Healthcare Safety Investigation Branch; February 17, 2022.

Pre-hospital emergency care can be vulnerable to timing, information, and task failures that compromise safety. This investigation explores how computerized decision support system access played a roles in an emergency call-center program incident where erroneous information was transmitted to a pregnant patient that contributed to infant harm.

Preventing home medication administration errors.

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Yin HS, Neuspiel DR, Paul IM, et al. Pediatrics. 2021;148:e2021054666.

Children with complex home care needs are vulnerable to medication errors. This guideline suggests strategies to enhance medication safety at home that include focusing on health literacy, prescriber actions, dosing tool appropriateness, communication, and training of caregivers. A March 18, 2022 webinar will highlight factors contributing to medication errors in the home and outline strategies to reduce their impact.

She was headed to a locked psych ward. Then an ER doctor made a startling discovery.

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Boodman SG. Washington Post. February 12, 2022.

Misdiagnosis over a long period of time can be acerbated by stigma and cognitive bias. This news story illustrates the problem of omissions due to potential stigma associated with patient mental health issues that contributed to a missed diagnosis. The author discusses how clinician experience led to flagging of a different testing approach to reveal a diagnosis that, once addressed, improved the patient's health.

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