The PSNet Collection

Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals.

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Washington, DC: Leapfrog Group; July 2022.

Diagnostic safety is beginning to be established as a systemic, rather than solely an individual performance issue. This report recommends strategies that support systemic work toward diagnostic excellence and selected implementation stories that illustrate success. It is a part of a larger initiative devoted to the improvement of organizational and team activities in tandem with clinical processes to minimize the impact of human error on diagnosis.

Examining the Status of VA’s Electronic Health Record Modernization Program.

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US Senate Committee on Veterans Affairs. 117th Cong (2021-2022). (July 20, 2022).

Large-scale electronic health record (EHR) implementation projects encompass a myriad of problems to navigate to arrive at success. This Congressional panel explores challenges experienced during EHR implementation in the VA Health system. Panelists from the Veterans Administration, the investigator and the technology vendor involved in the program shared insights and next steps to direct improvement.

An evolution of reporting: identifying the missing link.

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Harsini S, Tofighi S, Eibschutz L, et al. Diagnostics (Basel). 2022;12:1761.

Incomplete or delayed communication of imaging results can result in harm to the patient and have legal ramifications for the providers involved. This commentary presents a closed-loop communication model for the ordering clinician and radiologist. The model suggests the ordering clinician categorize the radiology report as “concordant” or “discordant”, and if discordant, provide an explanation.

Do patient engagement IT functionalities influence patient safety outcomes? A study of US hospitals.

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Upadhyay S, Opoku-Agyeman W, Choi S, et al. J Public Health Manag Pract. 2022;28:505-512.

Patient engagement is a key element of successful patient safety improvement efforts, including those leveraging health information technology (IT) approaches. This longitudinal study using a national sample of hospitalizations identified a significant association between patient engagement and electronic health record (EHR) adoption with the incidence of adverse events.

The Uneven Burden of Maternal Mortality in the U.S.

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NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.

Preventable maternal morbidity is an ongoing challenge in the United States. This infographic shares general data and statistics that demonstrate the presence of racial disparities in maternal care that are linked to structural racism. The resource highlights several avenues for improvement such as diversification of the perinatal staffing and increased access to telehealth.

Criminal liability for nursing and medical harm.

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Maher V, Cwiek M. Hosp Top. 2022;Epub Jul 20.

Fear of criminal liability may inhibit clinicians from reporting medical errors, thereby reducing opportunities for learning. This commentary discusses recent legal actions brought against clinicians, including Tennessee nurse RaDonda Vaught, and the negative impact such actions may have on the longstanding disclosure movement.

Preventing retained surgical items.

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Weston M, Chiodo C. AORN J. 2022;115:569-575.

Unintentionally retained foreign objects can be exacerbated by fatigue, distractions, and communication errors. This article highlights the importance of effective teamwork, high reliability orientation, and standardized surgical count methods to minimize the persistent problem of retained surgical items.

Translating electronic health record-based patient safety algorithms from research to clinical practice at multiple sites.

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Zimolzak AJ, Singh H, Murphy DR, et al. BMJ Health Care Inform. 2022;29(1):e100565.

Patient safety algorithms developed through research must also be implemented into clinical practice. This article describes the process of translating an electronic health record-based algorithm for detecting missed follow-up of colorectal or lung cancer testing, from research into practice. All 12 test sites were able to successfully implement the trigger and identify appropriate cases.

Making electronic health records both SAFER and SMARTER.

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Johnson KB, Stead WW. JAMA. 2022;Epub Jul 14.

Electronic health record (EHR) system implementation should optimize interoperability and support clinician decision making. This commentary discusses a strategy to aid in the sociotechnical design of interfaces and involvement of the myriad of individuals that use EHRs, including patients.

The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm.

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Washington, DC: VA Office of the Inspector General; July 14 2022. Report No. 22-01137-204.

Problems with clinician order delivery can result in harmful care delays. This report discusses how an electronic health record (EHR) system sent thousands of requests for medical care in a large health system to no location rather than to the intended site for care. These misattributions contributed to 142 patient safety events. The analysis highlighted factors contributing to the EHR misdistribution of orders and shared concerns that the organization’s approach to reduce the risk for misrouted orders lacks effectiveness.

High-reliability organisation principles implemented in dentistry.

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Minyé HM, Benjamin EM. Br Dent J. 2022;232:879-885.

High reliability organization (HRO) principles used in other high-risk industries (such as aviation) can be applied patient safety. This article provides an overview of how HRO principles (preoccupation with failure, situational awareness, reluctance to simplify, deference to expertise, and commitment to resilience) can be successfully applied in dentistry.

Medication orders with future start dates: how far away Is too far?

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Medication Safety Alert! Acute care edition. July 14, 2022:27(14):1-4.

Human errors that occur while interacting with electronic health record (EHR) systems can impact patients. This article discusses a keystroke error that delayed the scheduling of an antibiotic for one year. Recommendations to mitigate the potential for similar errors include risk assessment, hard stop use, and daily medication review.

Room of hazards: a comparison of differences in safety hazard recognition among various hospital-based healthcare professionals and trainees in a simulated patient room.

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Wang M, Banda B, Rodwin BA, et al. J Patient Saf. 2022;Epub May 16.

Prior studies have examined students’ ability to recognize safety hazards in patient rooms using simulation; however, most of these studies focus on a single type of healthcare provider (e.g., medical or nursing students). This study compared physicians, nurses, and other healthcare workers and found that nurses identified more hazards than other providers. All healthcare workers were challenged to identify hazards of omission and those requiring two-step thinking.

Measure Dx: A Resource to Identify, Analyze, and Learn from Diagnostic Safety Events.

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Rockville, MD: Agency for Healthcare Research and Quality; July 2022. AHRQ Publication No. 22-0038.

Diagnostic improvement continues to gain focus as a goal in health care. The Measure Dx tool provides teams with guidance and strategies to detect and learn from diagnostic errors in their organizations. It includes a checklist to gauge readiness for implementation, measurement strategies, and recommendations for analyzing data and translating findings into front line care.

Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm.

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Wolf L, Gorman K, Clark J, et al. J Patient Saf. 2022;Epub May 25.

Human factors play an important role in contributing to and preventing adverse events. This study found that integrating human factors into a new root cause analysis process led to an increase in the number of strong interventions implemented after adverse events.

Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals.

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Xiao Y, Smith A, Abebe E, et al. J Patient Saf. 2022;Epub May 22.

Older adults are particularly vulnerable to medication errors due to polypharmacy and medical complexities. In this qualitative study, healthcare professionals outlined several multifactorial hazards for medication-related harm during care transitions, including complex dosing, knowledge gaps, errors in discharge medications and gaps in access to care.

Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care innovation.

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Atkinson MK, Benneyan JC, Bambury EA, et al. Health Care Manage Rev. 2022;47:E50-E61.

Patient safety learning laboratories (PSLL) encourage a cross-disciplinary, collaborative approach to problem solving. This study reports on how a learning ecosystem supported the success of three distinct PSLLs. Qualitative and quantitative results reveal four types of alignment and supporting practices that contribute to the success of the learning laboratories.

Factors associated with malpractice claim payout: an analysis of closed emergency department claims.

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Gupta K, Szymonifka J, Rivadeneira NA, et al. Jt Comm J Qual Patient Saf. 2022;Epub May 28.

Analysis of closed malpractice claims can be used to identify potential safety hazards in a variety of clinical settings. This analysis of closed emergency department malpractice claims indicates that diagnostic errors dominate, and clinical judgment and documentation categories continue to be associated with a higher likelihood of payout. Subcategories and contributing factors are also discussed.

Provider implicit bias: bringing awareness to clinical practice.

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Moss LD. Clinical Advisor. June 29, 2022.

Health disparities perpetuated by structural racism degrade patient safety. This article discusses the influence of implicit biases on care delivery and highlights the increased interest and research being generated to improve understanding and initiative design to reduce the impact of implicit bias on care.

Dashboard design to identify and balance competing risk of multiple hospital-acquired conditions.

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Makic MBF, Stevens KR, Gritz RM, et al. Appl Clin Inform. 2022;13:621-631.

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).

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