Fawzy A, Wu TD, Wang K, et al. JAMA Intern Med. 2022;Epub May 31.
Black and brown patients have experienced disproportionately poorer outcomes from COVID-19 infection as compared with white patients. This study found that patients who identified as Asian, Black, or Hispanic may not have received timely diagnosis or treatment due to inaccurately measured pulse oximetry (SpO2). These inaccuracies and discrepancies should be considered in COVID outcome research as well as other respiratory illnesses that rely on SpO2 measurement for treatment.
Milliren CE, Bailey G, Graham DA, et al. J Patient Saf. 2022;18:e741-e746.
The Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS) use a variety of quality indicators to measure and rank hospital performance. In this study, researchers analyzed the variance between AHRQ pediatric quality indicators and CMS hospital-acquired condition indicators and evaluated the use of alternative composite scores. The researchers identified substantial within-hospital variation across the indicators and could not identify a single composite measure capable of capturing all of the variance observed across the broad range of outcomes. The authors call for additional research to identify meaningful approaches to performance ranking for children’s hospitals.
Lam JYJ, Barras M, Scott IA, et al. Drugs Aging. 2022;39:333-353.
Patient characteristics such as age, comorbidities and frailty can increase risk for medication errors. This scoping review shows that studies evaluating medication harm in frail patients are largely limited the methodological quality and inadequate reporting. The authors discuss the need for more robust studies examining this relationship, including the effect of polypharmacy.
Baim-Lance A, Ferreira KB, Cohen HJ, et al. J Gen Intern Med. 2022;Epub May 17.
When serious adverse events such as death are reported, they are typically associated with poor patient safety. In some fields of care, however, such as palliative care, deaths are expected and not necessarily an indicator of poor quality. This commentary describes how serious and non-serious adverse events (SAEs/AEs) are currently defined and reported, the associated challenges, and proposes a new approach to reporting SAE/AE in clinical trials. A decision-tree to determine SAE/AE reporting based on the new proposed approach is presented.
Mortensen M, Naustdal KI, Uibu E, et al. BMJ Open Qual. 2022;11:e001751.
A 2011 systematic review identified nine tools to assess patient safety competence in nurses. This review identified multiple instruments released since that review; the most frequently used was the Health Professional Education in Patient Safety Survey (H-PEPSS). The authors suggest future research should consider including ethics in patient safety and responsiveness to change over time.
Fontil V, Khoong EC, Lyles C, et al. Jt Comm J Qual Patient Saf. 2022;Epub May 5.
Missed or delayed diagnosis in primary care may result in serious complications for patients. This prospective study followed adults presenting to primary care with new or unresolved symptoms for 12 months. 32% of patients received a diagnosis within one month; most of the rest still did not have a diagnosis at 12 months (50%). The authors suggest interventions aimed at improving diagnosis should be system-based, not specific to a single medical issue or population.
Krenzischek DA, Card E, Mamaril M, et al. J Perianesth Nurs. 2022;Epub Apr 27.
Patients and caregivers are important partners in promoting safe care. Findings from this cross-sectional study reinforce the importance of patients’ perceived roles in ensuring safe surgery and highlight the importance of patient engagement in mitigating surgical site errors.
Driesen BEJM, Baartmans M, Merten H, et al. J Patient Saf. 2022;18:342-350.
Root cause analysis (RCA) is widely used to investigate, monitor, and learn from unintended events (UE). One method of RCA is the Prevention and Recovery Information System for Monitoring and Analysis (PRISMA)-method. This review identified 25 studies that used the PRISMA method to analyze UEs. Combining record reviews with provider interviews and using multiple PRISMA-trained researchers may increase the number of causes identified.
Checklists are used to improve patient outcomes in a wide variety of clinical settings and processes, such as childbirth, surgery, and diagnosis. This review applied the Systems Engineering Initiative for Patient Safety 2.0 (SEIPS 2.0) human factors framework to 25 diagnostic checklists. Checklists were characterized within the three primary components (work systems, processes, and outcomes) and subcomponents. Checklists addressing the Task subcomponent were associated with a reduction in diagnostic errors. Several subcomponents were not addressed (e.g. External Environment, Organization) and present an opportunity for future research.
Ramani S, Halpern TA, Akerman M, et al. Am J Obstet Gynecol. 2022;226:556.e1-556.e9.
Cesarean delivery can lead to adverse outcomes and is commonly used as a measure of obstetrical quality; however, these measures do not account for preexisting maternal and neonatal morbidities, which may increase risk for cesarean delivery. This article describes the development and testing of a new obstetrical quality measure that integrates cesarean delivery rates adjusted for preexisting high-risk maternal factors as well as maternal and neonatal morbidities. Among obstetricians in one large hospital, researchers found that this metric led to significantly different clinician rankings in terms of obstetrical quality (compared to rankings based on crude or adjusted cesarean delivery rates alone.) The authors suggest that this new metric can help identify opportunities for practice improvement among individual clinicians and institutions.
Structured handoffs support appropriate communication between teams or departments when transferring responsibility for care. This meta-analysis aimed to determine if structured, standardized post-operative anesthesia handoffs improved provider, patient, organizational and handoff outcomes. Postoperative outcomes moved in a generally positive direction when compared with non-standardized handoffs. The authors suggest additional research into pre- and intra-operative handoffs is needed.
Sheehan JG, Howe JL, Fong A, et al. J Patient Saf. 2022;Epub Apr 28.
Patient safety event reporting systems are a core component of patient safety and quality improvement. In this study, researchers identified seven publicly available patient safety databases that can be used to identify patient safety risks and opportunities for improvement.
Public reporting of safety measures is considered a hallmark of health care transparency. This article discusses a proposed change to reporting requirements in the Hospital-Acquired Condition Reduction Program (HACRP). The change would limit the sharing of patient safety indicator data that informs Care Compare and hospital Medicare reimbursements.
Rockville, MD: Agency for Healthcare Research and Quality; 2019.
The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey and accompanying toolkit were developed to collect opinions of hospital staff on the safety culture at their organizations. An accompanying database serves as a central repository for hospitals to report their results. Participating hospitals will be able to measure patient safety culture in their institutions and compare results with other sites. Data will be collected for the latest submission period from June 1–July 22, 2022.
Giardina TD, Hunte H, Hill MA, et al. J Patient Saf. 2022;Epub Apr 27.
The 2015 National Academies of Science, Engineering, and Medicine (NASEM) report Improving Diagnosis in Healthcare defined diagnostic error as “the failure to (a) establish an accurate and timely explanation of the patient's health problem(s) or (b) communicate that explanation to the patient.” This review and interviews with subject matter experts explored how the NASEM definition of diagnostic error has been operationalized in the literature. Of the sixteen included studies, only five operationalized the definition and only three studied communicating with the patient. The authors recommend formulating a set of common approaches to operationalize each of the three components of the NASEM definition. Patients and family should be included in defining the construct of “communication to the patient.”
Bradford A, Shahid U, Schiff GD, et al. J Patient Saf. 2022;Epub Apr 21.
Common Formats for Event Reporting allow organizations to collect and share standardized adverse event data. This study conducted a usability assessment of AHRQ’s proposed Common Formats Event Reporting for Diagnostic Safety (CFER-DS). Feedback from eight patient safety experts was generally positive, although they also identified potential reporter burden, with each report taking 30-90 minutes to complete. CFER-DS Version 1.0 is now available.
Feng T-ting, Zhang X, Tan L-ling, et al. J Nurs Adm. 2022;52:160-166.
When reported and investigated, near misses provide a unique learning opportunity for individuals and organizations. This scoping review of the literature on near misses identifies contributing factors (organizational, human, and technical); barriers and facilitators to reporting; and quality improvement projects to improve reporting of near misses.
Joseph K, Newman B, Manias E, et al. Patient Educ Couns. 2022;Epub Apr 26.
Lack of patient engagement in care can place them at increased risk for safety events. This qualitative study explored ethnic minority stakeholder perspectives about patient engagement in cancer care. Focus groups consisting of participants from consumer and health organizations involved in cancer care in Australia identified three themes supporting successful engagement – consideration of sociocultural beliefs about cancer, adaptation of existing techniques tailored to stakeholders (e.g., culturally specific content), and accounting for factors such as cultural competence during implementation.
Adverse drug events (ADEs) can result in serious patient harm. This systematic review of 62 studies found that hospitalizations related to ADEs ranged from 10 to 383 events per 100,000 people, whereas deaths due to ADEs ranged from 0.1 to 8 per 100,000 people.
Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.
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