The PSNet Collection

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.

Challenges of Diabetes Management and Medication Reconciliation

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August 5, 2022

This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to compile the ‘best possible medication history’, and how pharmacy staff roles and responsibilities can reduce medication errors.

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.

From COVID-19 pandemic to patient safety: a new "spring" for telemedicine or a boomerang effect?

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De Micco F, Fineschi V, Banfi G, et al. Front Med (Lausanne). 2022;9:901788.

The COVID-19 pandemic led to a significant increase in the use of telehealth. This article summarizes several challenges that need to be addressed (e.g., human factors, provider-patient relationships, structural, and technological factors) in order to support continuous improvement in the safety of health care delivered via telemedicine.

Support methods for healthcare professionals who are second victims: an integrative review.

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Neft MW, Sekula K, Zoucha R, et al. AANA J. 2022;90(3):189-196.

Healthcare workers who are involved in a patient safety incident may experience adverse psychological outcomes. This integrative review summarizes the importance of organizational safety culture and highlights strategies and programs (such as the RISE support program and peer support teams) for supporting healthcare professionals after involvement in a patient safety incident.

Who killed patient safety?

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Hemmelgarn C, Hatlie MJ, Sheridan S, et al. J Patient Saf Risk Manage. 2022;27:56-58.

This commentary, authored by patients and families who have experienced medical errors, argues current patient safety efforts in the United States lack urgency and commitment, even as the World Health Organization is increasing its efforts. They call on policy makers and safety agencies to collaborate with the Patients for Patient Safety US organization to move improvement efforts forward.

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.

Family safety reporting in hospitalized children with medical complexity.

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Mercer AN, Mauskar S, Baird JD, et al. Pediatrics. 2022;150:e2021055098.

Children with serious medical conditions are vulnerable to medical errors. This prospective study examined safety reporting behaviors among parents of children with medical complexity and hospital staff caring for these patients in one tertiary children’s hospital. Findings indicate that parents frequently identify medical errors or quality issues, despite not being routinely advised on how to report safety concerns.

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.

Missing a Large Vessel Occlusion Stroke in a Patient with a History of Seizures.

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July 8, 2022

A 58-year-old man with a past medical history of seizures presented to the emergency department (ED) with acute onset of left gaze deviation, expressive aphasia, and right-sided hemiparesis. The patient was evaluated by the general neurology team in the ED, who suspected an acute ischemic stroke and requested an evaluation by the stroke neurology team but did not activate a stroke alert. The stroke team concluded that the patient had suffered a focal seizure prior to arrival and had postictal deficits.

Preventable Transfer to the Hospital

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July 8, 2022

This WebM&M describes a 78-year-old veteran with dementia-associated aggressive behavior who was hospitalized multiple times over several months for hypoxic respiratory failure and atrial fibrillation before being discharged to a skilled nursing facility. The advanced care planning team, in consultation with palliative care and ethics experts, determined that transition to hospice was appropriate. However, these recommendations were verbally communicated and not documented in the chart.

Distinguishing high-performing from low-performing hospitals for severe maternal morbidity: a focus on quality and equity.

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Howell EA, Sofaer S, Balbierz A, et al. Obstet Gynecol. 2022;139:1061-1069.

Health equity in maternal safety is a major patient safety goal. Researchers interviewed health care professionals, including frontline nurses and physicians, chief medical officers, and quality and safety officers, from high- and low-performing hospitals. Six themes emerged differentiating high and low performers: 1) senior leadership involved in day-to-day quality activities and dedicated to quality improvement, 2) a strong focus on standards and standardized care, 3) strong nurse-physician communication and teamwork, 4) adequate physician and nurse staffing and supervision, 5) sharing of performance data with nurses and other frontline clinicians, and 6) explicit awareness that racial and ethnic disparities exist and that racism and bias in the hospital can lead to differential treatment. PSNet offers a Patient Safety Primer and Curated Library on maternal safety.

Family safety reporting in medically complex children: parent, staff, and leader perspectives.

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Khan A, Baird JD, Kelly MM, et al. Pediatrics. 2022;149:e2021053913.

Patient and family engagement in safety efforts is supported in research but patients and clinicians still experience barriers in providing and accepting feedback. In this study, parents and caregivers of medically complex children reported uncertainty about whether and to whom to report concerns. Other themes included misalignment of staff and parent expectations of care and staff and leadership buy-in on the value of parent engagement.

Differences in medication reconciliation interventions between six hospitals: a mixed method study.

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Stuijt CCM, van den Bemt BJF, Boerlage VE, et al. BMC Health Serv Res. 2022;22:722.

Medication reconciliation can reduce medication errors, but implementation practices can vary across institutions. In this study, researchers compared data for patients from six hospitals and different clinical departments and found that hospitals differed in the number and type of medication reconciliation interventions performed. Qualitative analysis suggests that patient mix, types of healthcare professionals involved, and when and where the medication reconciliation interviews took place, influence the number of interventions performed.

Handoffs and teamwork: a framework for care transition communication.

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Webster KLW, Keebler JR, Lazzara EH, et al. Jt Comm Qual Patient Saf. 2022;48:343-353.

Effective handoff communication is a key indicator of safe patient care. These authors outline a new model for handoff communication, integrating three theoretical frameworks addressing relevant inputs (i.e., individual organizational, environmental factors), mediators (e.g., communication, leadership), outcomes (e.g., patient, provider, teamwork, and organizational outcomes), and adaptation loops.

Visitor behaviors can influence the risk of patient harm: an analysis of patient safety reports from 92 hospitals.

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Sanchez C, Taylor M, Jones RM. Patient Safety. 2022;4:70-79.

Families and caregivers play an important role in patient safety. This study analyzed incident report data and found that behavior from families and caregivers visiting a patient increased the risk of patient harm in 36% of cases and decreased the risk of harm in the remaining 64% of cases. Certain visitor behaviors (such as moving the patient) increased patient harm, including falls and medication-related events. Other behaviors, such as communicating with healthcare staff, decreased patient harm.

Association of patient and family reports of hospital safety climate with language proficiency in the US.

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Khan A, Parente V, Baird JD, et al. JAMA Pediatr. 2022;176:776-786.

Parent or caregiver limited English proficiency (LPE) has been associated with increased risk of their children experiencing adverse events. In this study, limited English proficiency was associated with lower odds of speaking up or asking questions when something does not appear right with their child’s care. Recommendations for improving communication with limited English proficiency patients and families are presented.

Experiences of transgender people reviewing their electronic health records, a qualitative study.

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Alpert AB, Mehringer JE, Orta SJ, et al. J Gen Intern Med. 2022;Epub May 31.

Transgender patients who experience or perceive bias when receiving care may avoid or delay seeking care in the future. In this study, transgender patients reported on their experiences in viewing their electronic health record (EHR). In line with previous studies, transgender patients reported experiencing harms in several ways, such as providers using the wrong pronouns, wrong name, or wrong gender marker. The structure of the EHR (e.g., no separate fields for sex and gender) itself also created barriers to quality care.

TeamSTEPPS Master Training Course.

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Armstrong Institute for Patient Safety and Quality. October 4 and 6, 2022.

Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model.

Prevention of perioperative medication errors.

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Nanji K. UpToDate. June 23, 2022.

Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical setting and discusses prevention strategies that focus on medication reconciliation, technology, standardization, and institutional change.

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