The PSNet Collection

A blueprint for success: implementation of the Center for Medicare and Medicaid Services mandated anesthesiology oversight for procedural sedation in a large health system.

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Abdelmalak BB, Adhami T, Simmons W, et al. Anesth Analg. 2022;Epub May 12.

A 2009 CMS Condition of Participation (CoP) requires that a director of anesthesia services assume overall responsibility for anesthesia administered in the hospital, including procedural sedation provided by nonanesthesiologists. This article reviews the CoP as it relates to procedural sedation, lays out a framework for implementing this role, and describes challenges of implementation in a large health system.

A retrospective review of serious surgical incidents in 5 large UK teaching hospitals: a system-based approach.

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Serou N, Slight RD, Husband AK, et al. J Patient Saf. 2022;18:358-364.

Operating rooms are high-risk healthcare settings. This study reviewed serious surgical incidents occurring at large teaching hospitals in one National Health Service (NHS) trust. The authors outline several possible contributing factors (i.e., equipment and resource factors, team factors, work environment factors, and organizational and management factors) discuss recommendations for safer care.

Hospital-wide cardiac arrest in situ simulation to identify and mitigate latent safety threats.

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Bentley SK, Meshel A, Boehm L, et al. Adv Simul (Lond). 2022;7:15.

In situ simulations are an effective method to identify latent safety threats (LST). Seventy-four in situ cardiac arrest simulations were conducted in one hospital, identifying 106 unique LSTs. Four LSTs were deemed imminent safety threats and were immediately resolved following debrief; another 15 were prioritized as high-risk.

Safety gaps in medical team communication: closing the loop on quality improvement efforts in the cardiac catheterization lab.

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Doorey AJ, Turi ZG, Lazzara EH, et al. Catheter Cardiovasc Interv. 2022;Epub Apr 14.

Closed loop communication (CLC) ensures a clear transfer of information by having the recipient repeat the order for verification. In this study, procedures in the cardiac catheterization lab were observed to assess the frequency and accuracy of CLC. Despite three interventions over five years (education, on-going feedback, accountability), CLC remained suboptimal, with both incomplete orders given and incomplete responses.

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.

Identifying patients whose symptoms are underrecognized during treatment with breast radiotherapy.

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Jagsi R, Griffith KA, Vicini F, et al for the Michigan Radiation Oncology Quality Consortium. JAMA Oncol. Epub 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.

Quality Special Issue.

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J Med Imaging Radiat Oncol. 2022;66(2):165-309.

Improving patient safety related to radiology and radiation oncology is an ongoing priority. This special issue explores themes related to radiology and radiation oncology, including monitoring and improving quality of care, promoting a culture of safety, and measuring, reporting, and learning from errors.

Learning environments, reliability enhancing work practices, employee engagement, and safety climate in VA cardiac catheterization laboratories.

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Gilmartin HM, Hess E, Mueller C, et al. Health Serv Res. 2022;57:385-391.

Ideal clinical learning environments (CLE) support employee engagement, satisfaction, and a culture of safety. The Learning Environment and High Reliability Practices Survey (LEHR) was used to determine the association between ideal CLE and job satisfaction, burnout, intent to leave, and staff turnover. Learning environments with higher average LEHR scores were associated with higher employee engagement, retention, and safety climate scores.

Delayed Diagnosis of Kidney Transplant Complications

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February 23, 2022

A 69-year-old man with End-Stage Kidney Disease (ESKD) secondary to diabetes mellitus and hypertension, who had been on dialysis since 2014, underwent deceased donor kidney transplant. The case demonstrates the complex nature of management of allograft dysfunction due to vascular complications in a patient with deceased donor kidney transplant in the early post-transplant period.

Preventing and mitigating radiology system failures: a guide to disaster planning.

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Gibney BT, Roberts JM, D'Ortenzio RM, et al. RadioGraphics. 2021;41:2111-2126.

Hospitals are increasingly creating and updating their emergency disaster response plans. This guide assists hospital executives, quality & safety professionals, and risk managers by assessing potential hazards or failures in radiology departments in the event of disaster. Disaster planning tools, checklists, and other recommendations are described.

Prep, Stop, Block.

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RA-UK, the Faculty of Pain Medicine, RCoA Simulation and NHS Improvement

Standardization is a common strategy for preventing practice deviations that can contribute to harm. This tool outlines a three-step process for minimizing the occurrence of wrong-side peripheral nerve blocks that involves preparing for the procedure, stopping to perform a two-person site confirmation, and then administering the block.

Misdiagnosis of acute myocardial infarction: a systematic review of the literature.

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Kwok CS, Bennett S, Azam Z, et al. Crit Pathw Cardiol. 2021;20:155-162.

Misdiagnosis of cardiovascular conditions can lead to serious patient harm. This systematic review found that misdiagnosis of acute myocardial infarction (AMI) occurs in approximately 1-2% of cases, and AMI is commonly diagnosed as other heart conditions, musculoskeletal pain, or gastrointestinal disease. The authors suggest that there are opportunities to reduce cases of missed AMI with better education about atypical symptoms and improved training of electrocardiogram interpretation.

A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency.

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Warm EJ, Ahmad Y, Kinnear B, et al. Acad Med. 2021;96:1268-1275.

Technical and procedural skills are an important emphasis of medical training. This article briefly summarizes the “as low as reasonably achievable” (ALARA) approach, which was developed for the nuclear industry and has been used in radiology. The authors outline how ALARA risk standards can be adapted by training program directors to measure procedural competency and assess and reduce bedside procedural risks.

Simulation-based education enhances patient safety behaviors during central venous catheter placement.

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Jagneaux T, Caffery TS, Musso MW, et al. J Patient Saf. 2021;17:425-429.

Emergency and internal medicine residents attended a course on central venous access that included lectures, videos, and simulation using a task trainer. Comparison of pre- and post-training evaluation demonstrated significant improvement in knowledge, confidence, and procedural skills.

Curated Libraries

Maternal Safety

Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: is there a July effect?

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Metersky ML, Eldridge N, Wang Y, et al. J Patient Saf. 2022;18:253-259.

The July Effect is a belief that the quality of care delivered in academic medical centers decreases during July and August due to the arrival of new trainees. Using data from the Medicare Patient Safety Monitoring System, this retrospective cohort, including over 185,000 hospital admissions from 2010 to 2017, found that patients admitted to teaching hospitals in July and August did not experience higher rates of adverse events compared to patients admitted to non-teaching hospitals.

Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen-year period.

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Le Cornu E, Murray S, Brown EJ, et al. J Med Radiat Sci. 2021;68:356-363.

Use of health information technology (HIT) can improve care but also lead to unexpected patient harm. In this analysis of incidents and near misses in radiation oncology, a major change in the use of the electronic health record (EHR) led to an increase in reported incidents and near misses. Leaders and HIT professionals should be aware of potential issues and develop a plan to minimize risk prior to major departmental changed including EHR changes.

Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals.

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Chopra V, O'Malley M, Horowitz J, et al. BMJ Qual Saf. 2022;31:23-30.

Peripherally inserted central catheters (PICC) represent a key source of preventable harm. Using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), the authors sought to determine if the appropriateness of PICC use decreased related medical complications including catheter occlusion, venous thromboembolism, and central line-associated bloodstream infections. Use of MAGIC in 52 Michigan hospitals increased appropriate use of PICC lines and decreased medical complications. In a 2019 PSNet Perspective, Dr. Vineet Chopra described the development and implementation of MAGIC in Michigan hospitals.

Quality and Safety in Health Care.

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Harolds JA, Harolds LB. Clin Nucl Med. 2015–2021.

This monthly commentary explores a wide range of subjects associated with patient safety, such as infection prevention, surgical quality improvement, and high reliability organizations.

Wrong-site surgery in Pennsylvania during 2015–2019: a study of variables associated with 368 events from 178 facilities.

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Yonash RA, Taylor M. Patient Safety. 2020;2:24-39.

Wrong-site surgeries can lead to serious patient harm and are considered never events by the National Quality Forum. Based on events reported to the Pennsylvania Patient Safety Reporting System between 2015 and 2019, the authors identified an average of 1.42 wrong-site surgery events per week and found that three-quarters of events resulted in temporary or permanent patient harm. The authors present several evidence-based strategies to reduce the likelihood of wrong-site surgery, including preoperative and intraoperative verification, site marking, and timeouts.

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