Barba V, Foreman K, Robey K. Int J Healthc Manag. 2021;14(3):926-932.
This article describes the efforts towards high reliability undertaken by one specialty hospital for medically complex children and adults with intellectual and development disabilities. The organization employed a multi-pronged, data-driven approach involving training and education in quality management and patient safety and principles of high reliability organizations. Improvements in medication errors and hospital-acquired pressure injuries were observed, but employee engagement survey results reflect concern among staff that an emphasis on data may detract from patient care.
Hess E, Palmer SE, Stivers A, et al. J Oncol Pharm Pract. 2019:1078155219870590.
Chemotherapy administration is a potential source for errors. This study evaluated trends in chemotherapy error reporting before and after EHR implementation. Errors arising from the wrong dose decreased after EHR implementation, while errors arising from missing dose or delayed delivery increased.
This retrospective study of dental patient safety reports in the military health system demonstrated an increase in reported events, which may reflect improvements in safety culture. Wrong-site surgery was the most common adverse event, suggesting the need to enhance safety practices in dentistry.
Ashfaq HA, Lester CA, Ballouz D, et al. JAMA Ophthalmol. 2019.
This study examined the concordance between structured medication lists in the electronic health record and unstructured physician progress notes for antibiotic medications being used to treat keratitis, an eye infection. Researchers found that 23% of prescribed medications differed between the progress note and the structured medication list, highlighting the need for and the challenges in conducting medication reconciliation.
Marcus RK, Lillemoe HA, Caudle AS, et al. Ann Surg. 2019;270:937-941.
Although the introduction of new technology in health care is crucial for advancing patient care, unintended consequences are a well-recognized safety challenge. In the field of surgery, innovation ranges from small improvements to drastic change, but there is no clearly established model for evaluating proposed innovations. This study examined the impact of a team of surgical quality officers and perioperative nurses tasked with reviewing proposed surgical innovations, including novel devices and procedures at a single cancer center. Investigators found that compared to the prior processes in place, this team evaluated new products more quickly, decreased the time between product proposal and the intraoperative trial if necessary, and reduced the rate of device-related complications from 10% to 0%. A past PSNet perspective discussed the evolution of patient safety in the field of surgery.
Hoag JR, Resio BJ, Monsalve AF, et al. JAMA Netw Open. 2019;2:e191912.
This cross-sectional study examined outcomes for Medicare patients undergoing complex cancer surgery at U.S. News and World Report top-ranked cancer hospitals and their affiliates. Investigators found that surgery performed at affiliated hospitals was associated with higher 90-day mortality and that the top-ranked hospital was safer than its affiliates in 84% of the networks in the study. The authors suggest that while affiliated hospitals may share branding with top-ranked cancer facilities, further study of such networks is necessary to inform care for cancer patients.
Aviation continues to provide inspiration for patient safety innovation. This commentary describes a 10-minute team huddle exercise which involves team members rating their own mood status and the leader asking if there are any contextual concerns. In addition, two team members select "knowledge cards" that either test the person's knowledge or assign the person to proactively watch for improvement opportunities during the shift. The results encouraged sharing, situational awareness, and team building.
Rivich J, McCauliff J, Schroeder A. Addict Behav. 2018;86:40-43.
This study describes a quality improvement program that included chart review of patients taking high-dose opioids for noncancer pain and targeted feedback to clinicians with management recommendations. The program resulted in a decrease in overall opioid use as well as a reduction in coprescribing of benzodiazepines and opioids. Patient adherence to visits with their primary physician remained stable during the study period.
United States Government Accountability Office; GAO.
Ineffectively prescribed opioids contribute to opioid misuse and overdose among patients. This report analyzed activities at five Veterans Health Administration facilities and found inconsistent application of opioid safety strategies in the system. System-level recommendations to enhance practice include cross-system tracking efforts with defined goals and establishing a pain management leadership role at each facility.
As outpatient surgery becomes more prevalent, attention around related safety concerns grows. Researchers analyzed postprocedure emergency department visits and hospital admissions to better understand factors associated with the safety of outpatient procedures performed within the Veterans Health Administration.
Cherara L, Sculli GL, Paull DE, et al. J Patient Saf. 2021;17(8):e991-e928.
This study examined reports stemming from retained guidewires, a never event, across Veterans Affairs hospitals. Common causes included inexperience, lack of checklists, and insufficient standardization. The authors recommend applying human factors approaches to prevent this adverse event.
Washington, DC: Department of Veterans Affairs, Office of Inspector General. March 7, 2018. Report No. 17-02644-130.
Systemic weaknesses in the Veterans Affairs health system have resulted in high-profile failures. Highlighting concerns at one medical center that were found to contribute to opportunities for waste, fraud, and poor health care delivery, this report by the Office of Inspector General outlines 40 recommendations to address deficiencies.
Shah T, Patel-Teague S, Kroupa L, et al. BMJ Qual Saf. 2018;28.
Alert fatigue associated with electronic health records (EHRs) contributes to primary care physician burnout and can increase medication errors. The phenomenon is especially well-described in the Veterans Affairs (VA) system, where providers receive more than 100 alerts per day, which require an average of 85 seconds to address. This study describes a nationwide VA initiative to reduce EHR alerts in primary care and teach providers to process alerts more efficiently. Alerts decreased by a small but significant amount—from an average of 128 per day to an average of 116 per day. Providers who received the most alerts before the initiative experienced the largest alert reduction. A PSNet perspective described a way forward in improving EHR safety.
Following a hospital stay for a broken arm and dislocated shoulder, an older man was discharged to a skilled nursing facility (SNF) for rehabilitation. Providers were concerned about his ability to live independently given results of cognitive and living skills assessments performed during the hospital stay. Although the hospital social worker had begun the process of applying for home care and meals for the patient, the SNF discharged him home with no access to care, food, or his medications.
Malte CA, Berger D, Saxon AJ, et al. Med Care. 2018;56:171-178.
Opioid and benzodiazepine coprescribing leads to increased risk for medication adverse events. This interrupted time-series analysis demonstrated that a computerized provider order entry alert about opioid and benzodiazepine coprescribing led to decreases in coprescribing for high-risk patients compared to the time period before the alert was introduced and compared to a control site that did not receive the alert. The authors conclude that medication alerts can reduce high-risk prescribing practices.
A woman who had been taking naltrexone to treat alcohol use disorder was discharged to a skilled nursing facility (SNF) on opioids for pain following spinal fusion surgery. Although her naltrexone was held at the hospital in anticipation of starting opioids for pain control, the clinician performing medication reconciliation at the SNF overrode the drug–drug interaction alert and restarted the naltrexone. The SNF providers did not realize that the naltrexone blocked the pain-relieving effect of the opioids.
Schwartz ME, Welsh DE, Paull DE, et al. J Healthc Risk Manag. 2018;38(1):17-37.
Communication failures are known to contribute to medical errors. In the field of aviation, crew resource management is used to teach teamwork and effective communication. In this study, researchers evaluated the impact of a team training program developed by the Veterans Health Administration National Center for Patient Safety and modeled after crew resource management training. The Teamwork and Safety Climate Questionnaire was used to evaluate safety climate prior to and after the training. They found that scores on the 27-item survey increased on all questions from baseline to 1 year and conclude that this type of team training improves patient safety by enhancing teamwork and ensuring effective communication among clinicians. A PSNet perspective provides insights on team training.
Washington, DC: United States Government Accountability Office; November 2017. Publication GAO-18-63.
Tracking concerns related to individual clinician performance has the potential to uncover opportunities for clinician skill and system safety enhancements. This report highlights weaknesses in the peer reporting processes of Veterans Affairs medical centers and offers recommendations to improve the quality and timeliness of reporting to ensure safety of patients in the VA system.
Psychological safety can empower staff to communicate concerns that affect patient safety. This newspaper article reports on Veterans Affairs staff concerns about safety hazards, consequences whistle-blowers have faced after speaking up about problems, and efforts to protect whistle-blowers and improve the safety of the system.
King HB, Kesling K, Birk C, et al. Mil Med. 2017;182(3):e1612-e1619.
The Partnership for Patients is a government initiative to reduce health care–acquired conditions. This commentary describes a large-scale implementation of the Partnership for Patient methods across the Military Health System. The authors report the results of the program and recommend continuous leadership engagement to achieve success.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.