The PSNet Collection

Patient Safety in the Ambulatory Care Setting

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August 5, 2022

The focus on patient safety in the ambulatory setting was impacted by the COVID-19 pandemic and appropriately shifting priorities to responding to the pandemic. This piece explores some of the core themes of patient safety in the ambulatory setting, including diagnostic safety and diagnostic errors. Ways to enhance patient safety in the ambulatory care setting and next steps in ambulatory care safety are addressed.

The association of acute COVID-19 infection with Patient Safety Indicator-12 events in a multisite healthcare system.

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Bhakta S, Pollock BD, Erben YM, et al. J Hosp Med. 2022;17:350-357.

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.

HSJ Patient Safety Congress.

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Health Service Journal. September 15-16, 2022. Manchester Central Convention Complex, Manchester UK.

Patient safety is challenged worldwide due to the daily complexity of care. This session will focus on never events. Areas of specific exploration will include what factors in the environment enable never events, the value of proactive assessment of practice to prevent never events, and the viability of never event classification schemes.

Curated Libraries

COVID-19 Pandemic Impact on Healthcare Associated Conditions

Patient Safety Events and the Role of Patient Safety Organizations During the COVID-19 Pandemic

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January 12, 2022

This piece discusses patient safety challenges that arose as a result of the unique care circumstances surrounding the COVID-19 pandemic, particularly at the height of the pandemic in 2020.

In conversation with Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO

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January 12, 2022

Patient Safety Organizations (PSOs) are organizations dedicated to improving patient safety and healthcare quality that serve to collect and analyze data voluntarily reported by healthcare providers to promote learning.

NPSD Data Spotlight, Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency, 2021.

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Rockville, MD: Agency for Healthcare Research and Quality; November 2021. AHRQ Pub. No. 22-0005.

This analysis of reports submitted by Patient Safety Organizations during the early months of the COVID pandemic found that patients testing positive for COVID-19 or being investigated for carrying the virus was the most frequently reported patient safety concern (26.6%). In addition, patients and staff being exposed to individuals who had tested positive for COVID-19 was identified as a patient safety issue in 18.2% of the records analyzed.

Harnessing event report data to identify diagnostic error during the COVID-19 pandemic.

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Shen L, Levie A, Singh H, et al. Jt Comm J Qual Patient Saf. 2022;48:71-80.

The COVID-19 pandemic has exacerbated existing challenges associated with diagnostic error. This study used natural language processing to identify and categorize diagnostic errors occurring during the pandemic. The study compared a review of all patient safety reports explicitly mentioning COVID-19, and using natural language processing, identified additional safety reports involving COVID-19 diagnostic errors and delays. This innovative approach may be useful for organizations wanting to identify emerging risks, including safety concerns related to COVID-19.

The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary of data reported to the National Healthcare Safety Network.

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Weiner-Lastinger LM, Pattabiraman V, Konnor RY, et al. Infect Control Hosp Epidemiol. 2022;43:12-25.

Using data reported to the National Healthcare Safety Network, this study identified significant increases in the incidence of healthcare-associated infections from 2019 to 2020. The authors conclude that these findings suggest a need to return to conventional infection control and prevention practices and prepare for future pandemics.

Role of nursing home quality on COVID-19 cases and deaths: evidence from Florida nursing homes.

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Wang X, Wilson C, Holmes K. J Gerontol Soc Work. 2021:1-17.

Nursing home residents are especially vulnerable to COVID-19 due to their age and communal living conditions. Using publicly available data for nursing homes in Florida, this study explored the association between nursing home characteristics and COVID-19 cases and deaths. Findings suggest that the likelihood of COVID-19 cases in nursing homes is related to ownership status, facility size and average occupancy rate, rather than quality (as measured by infection prevention and control deficiencies).

Learning during crisis: the impact of COVID-19 on hospital-acquired pressure injury incidence.

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Polancich S, Hall AG, Miltner RS, et al. J Healthc Qual. 2021;43:137-144.

The COVID-19 pandemic has disrupted many aspects of health care delivery, including how hospitals prevent common hospital-acquired conditions such as pressure injuries. Based on retrospective data, the authors of this study did not identify a longitudinal increase in hospital-acquired pressure injuries between March and July 2020. The authors discuss how prior organizational efforts to reduce hospital-acquired pressure injuries allowed their hospital to quickly adapt existing workflows and processes to respond to the COVID-19 pandemic.

AHRQ PSNet Annual Perspective: Impact of the COVID-19 Pandemic on Patient Safety

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March 30, 2021

In this PSNet Annual Perspective, we worked with co-authors Dr. Jacqueline C. Stocking, a quality improvement and critical care specialist, and Dr. Christian Sandrock, a patient safety professional and emerging infectious diseases specialist, to provide a look at news and research related to the impact of the COVID-19 pandemic on patient safety.

The I-READI quality and safety framework: a health system’s response to airway complications in mechanically ventilated patients with Covid-19.

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Ginestra JC, Atkins JH, Mikkelsen ME, et al. NEJM Catalyst. 2020;2.

Health systems are rapidly adjusting and adapting processes to successfully respond to the COVID-19 pandemic. The University of Pennsylvania Health System developed the I-READI (integration, root cause analysis, evidence review, adaptation, dissemination, and implementation) conceptual framework to assist hospitals in preparing for and responding to patient safety challenges during times of crisis, such as the COVID-19 pandemic. The I-READI approach can streamline communication, enrich collaboration, and coordinate rapid change through the use of daily safety huddles, root cause analysis, and technology (e.g., ICU telemedicine and real-time ICU dashboards).

Nosocomial transmission and outbreaks of coronavirus disease 2019: the need to protect both patients and healthcare workers.

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Abbas M, Robalo Nunes T, Martischang R, et al. Antimicrob Resist Infect Control. 2021;10:7.

The large burden placed on hospitals and healthcare providers during the COVID-19 pandemic has raised concerns about nosocomial transmission of the virus. This narrative review summarizes existing reports on nosocomial outbreaks of COVID-19 and the strategies health systems have implemented to control healthcare-associated outbreaks. The authors found little evidence describing the role of healthcare workers in reducing or amplifying infection transmission in healthcare settings.

Healthcare failure mode and effect analysis (HFMEA) as an effective mechanism in preventing infection caused by accompanying caregivers during COVID-19-experience of a city medical center in Taiwan.

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Tiao C-H, Tsai L-C, Chen L-C, et al. Qual Manag Health Care. 2021;30:61-68.

Hospitals have needed to adapt workflow processes to optimize infection control in response to the COVID-19 pandemic. This article describes the use of healthcare failure mode and effects analysis (HFMEA) 4-step model to implement preventive risk assessment and workflow management for high-risk medical procedures during the pandemic and prevention of nosocomial infections.

Adverse events in Italian nursing homes during the COVID-19 epidemic: a national survey.

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Lombardo FL, Salvi E, Lacorte E, et al. Front Psychiatry. 2020;11:578465.

Long-term care and skilled nursing facilities are particularly vulnerable to COVID-19 infection; this increased risk may present other threats to patient safety. This survey of nursing homes in Italy found that one third of facilities reported at least one adverse event during the early weeks of the COVID-19 pandemic. Adverse events were more likely to occur in nursing homes with higher bed capacities, increased use of psychiatric drugs, and use of physical restraints. These findings can inform nursing homes creating mitigation plans.

Development of rapid response capabilities in a large COVID-19 alternate care site using Failure Modes and Effect Analysis with in situ simulation.

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Levy N, Zucco L, Ehrlichman RJ, et al. Anesthesiology. 2020;133:985-996.

This article describes the experience of one hospital in eastern Massachusetts implementing rapid response capabilities in an innovative, hybrid acute care-intensive care unit. Health system leadership used failure modes and effect analysis, process mapping, and on-site walkthroughs to identify potential hazards and opportunities for risk mitigation, as well as in situ simulation drills to facilitate team training.

Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic.

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Kasda EM, Robson C, Saunders J, et al. J Patient Saf Risk Manag. 2020;25:156-158.

This article describes one academic medical center’s use of the Donabedian framework to rapidly identify and mitigate COVID-19 related safety concerns. This data-driven approach to systems learning is generalizable beyond the current pandemic and can be applied to other organizational changes.

Another medical malpractice crisis?: Try something different.

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Sage WM, Boothman RC, Gallagher TH. JAMA. 2020;324:1395-1396.

The COVID-19 pandemic has generated numerous concerns in the healthcare industry, one of which is the potential for significant malpractice claims. This article discusses the possibility of a medical malpractice crisis in response to poor outcomes associated with COVID-19 and suggests that the industry follow an alternate path away from tort reform and legal actions. Alternatives such as communication and resolution programs can focus on patient safety principles such as transparency, redesign of systems to reduce adverse events, and patient and family support that could prevent traditional legal actions.

Impact of the initial response to COVID-19 on long-term care for people with intellectual disability: an interrupted time series analysis of incident reports.

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Schuengel C, Tummers J, Embregts PJCM, et al. J Intellect Disabil Res. 2020;64:817-824.

Patient safety reporting systems are essential to detecting safety events and quality problems. This study compared incident reporting at one Dutch long-term care facility for people with intellectual disabilities before and during the COVID-19 pandemic. The lockdown measures implemented in response to COVID-19 coincided with an increase in aggression incidents and a decrease in medication error reports.

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