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.
Few medical humanitarian organizations have patient safety reporting and analysis systems. Interviews with medical and paramedical staff working in international humanitarian organizations expressed high expectations for organizational leadership to establish clear patient safety and medical error management policies.
Managing errors that affect patients who lack decision-making capacity and a designated decision-maker is a new area of concern. This commentary discusses moral, ethical, legal, and clinical reasons for health care to examine how to respond when such a situation occurs. The authors hope to motivate development of needed protocols and best practices to ensure that this vulnerable patient population is respectfully and completely informed after medical errors.
Aaronson EL, Quinn GR, Wong CI, et al. J Healthc Risk Manag. 2019;39:19-29.
Malpractice risk in the outpatient setting is significant and claims often involve missed and delayed diagnoses. This retrospective study examined diagnostic error claims in outpatient general medicine to identify characteristics and causes of cancer misdiagnoses. Similar to a prior study, investigators found that missed cancer diagnosis is the leading type of diagnostic error in primary care, constituting nearly half of closed diagnostic claims. Contributing factors included failure or delay in test ordering or consultation. These findings suggest that improving test results management and consultative processes may reduce malpractice risk related to outpatient diagnosis. A previous WebM&M commentary discussed an incident involving a missed diagnosis of spinal cord injury in primary care.
Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Diagnosis (Berl). 2019;6:227-240.
Diagnostic errors are widely acknowledged as a common patient safety problem, but difficulty in measuring these errors has made it challenging to quantify their impact. This study utilized a large national database of closed malpractice claims to estimate the frequency and severity of diagnostic errors. Researchers also sought to determine the types of diagnoses most vulnerable to misdiagnosis. Missed or delayed diagnoses accounted for 21% of 55,377 claims analyzed, and the majority of these cases resulted in permanent disability or death. These findings corroborate earlier research on closed malpractice claims in primary care and emergency department settings. Investigators found that three groups of diagnoses accounted for the majority of closed claims and high-severity events: vascular events (such as myocardial infarction and stroke), infections (such as sepsis), and cancer. This study represents an important step forward in identifying areas for improvement in diagnosis, but caution should be exercised in extrapolating these results, since malpractice claims only account for a small proportion of all adverse events experienced by patients. A previous PSNet perspective discussed momentum in the field of diagnostic error over the past several years.
Petersen EE, Davis NL, Goodman D, et al. MMWR Morb Mortal Wkly Rep. 2019;68:423-429.
Maternal safety is a critical concern in health care, and prior studies have discussed racial and ethnic disparities in patient safety. The Centers for Disease Control and Prevention examined trends in pregnancy-related deaths between 2011 and 2015. This analysis found that black women had rates of maternal mortality 3.5 times that of white women; Native American/Alaska Native women had rates 2.5 times higher than white women. About 60% of deaths were deemed preventable, and leading causes included cardiovascular events such as venous thromboembolism, infection, and hemorrhage. The study team recommends implementing interventions at health system, provider, community, and patient levels to prevent maternal mortality. A recent Annual Perspective on maternal safety touched on the persistently higher death rates among black women and discussed national initiatives to improve outcomes in maternity care.
McMichael BJ, Van Horn L, Viscusi K. Stanford Law Rev. 2019;71:341-409.
Prior research has shown that patients prefer that errors and adverse events be fully disclosed to them by their providers. However, physicians may be hesitant to simultaneously express empathy out of fear that such an expression could be taken as an admission of fault that might result in litigation. As a result, 38 states and the District of Columbia passed apology laws, designed to make such apologetic statements inadmissible in court, but the effect of such laws on medical malpractice remains unknown. Using a dataset obtained from a large malpractice insurer, researchers analyzed claims against 90% of United States physicians by specialty over 8 years. They found that for physicians in nonsurgical fields, apology laws increased the risk of experiencing litigation as well as the average dollar amount paid to settle a claim. They did not find such an effect for surgeons. A past PSNet interview highlighted the challenges associated with disclosure and apology.
Mannion R, Davies H, Powell M, et al. J Health Organ Manag. 2019;33:221-240.
Organizational acceptance of accountability for failures and implementation of solutions are critical to improve safety. This review explores the impact of investigations focused at the individual, practice, and system levels. The authors describe design and operational failings at each level that enable purposeful or accidental patient harm.
Mora JC, Kaye AD, Romankowski ML, et al. Adv Anesth. 2018;36:231-249.
Closed claim analysis can identify care problems and inform improvement strategies. This review examined closed claims for anesthesia and identified types of injuries experienced by patients receiving anesthesia. Situational awareness, distractions, equipment problems, and pain medicine complications contributed to anesthesia malpractice claims.
Rollman JE, Heyward J, Olson L, et al. JAMA. 2019;321:676-685.
Researchers assessed the effectiveness of the Food and Drug Administration (FDA) Risk Evaluation and Mitigation Strategy in preventing inappropriate prescribing of transmucosal immediate-release fentanyl, high-risk opioid products with narrow prescribing indications. Survey data obtained from patients, providers, and pharmacists at various points after the FDA program's initiation suggested ongoing misunderstanding regarding appropriate prescribing. Analysis of claims data 5 years into the program revealed that anywhere from 35% to 55% of patients were prescribed transmucosal immediate-release fentanyl products inappropriately.
Chen Q, Larochelle MR, Weaver DT, et al. JAMA Netw Open. 2019;2:e187621.
Reducing opioid-related harm is a major patient safety priority. This simulation study used a mathematical model to predict the effect of existing opioid misuse interventions on opioid overdose mortality. The researchers compared the expected decline based on the current trend over time versus the effect of a 50% faster reduction in misuse. Their calculations suggest that interventions such as prescription drug monitoring programs and insurance coverage changes will result in only a small absolute decrease in opioid overdose deaths. The authors call for developing and testing other strategies for opioid safety. An Annual Perspective discussed the extent of harm associated with opioid prescribing and described promising practices to address opioid misuse.
Horn SR, Liu TC, Horowitz JA, et al. Spine (Phila Pa 1976). 2018;43:E1358-E1363.
This retrospective review of National Surgical Quality Improvement Program data on hospital-acquired conditions following elective spine surgery found that 3% of these cases had at least one hospital-acquired condition. The most common conditions were surgical site infection, followed by urinary tract infection and venous thromboembolism, all well-recognized conditions with known evidence-based prevention strategies.
Scholl L, Seth P, Kariisa M, et al. MMWR Morb Mortal Wkly Rep. 2018;67:1419-1427.
This Centers for Disease Control and Prevention report provides drug and opioid overdose death figures for 2016. The rate of overdose deaths continues to rise, with the largest increase due to synthetic opioids such as fentanyl. The report calls for enhancing prevention and response measures, including the use of naloxone.
Turner DA, Bae J, Cheely G, et al. J Gen Intern Care. 2018;10:671-675.
Voluntary reporting of safety events is a widespread patient safety practice, but safety events are known to be underreported, especially by physicians. This uncontrolled intervention study aimed to increase error reporting by residents and fellows by providing a financial incentive of about $200 to report at least two safety events per year. More than half of eligible trainee physicians received the incentive, and the resultant increase in safety reports was sustained over 3 years. One related commentary suggests providing team-based incentives instead of the individual payments, and another commentary questions whether increased safety reporting translates to safer care and urges caution in incentivizing event reporting. A past PSNet perspective discussed the effect of financial incentives on patient safety.
Kozhimannil KB. Health Aff (Millwood). 2018;37:1901-1904.
Maternal harm is a sentinel event that is gaining increased attention in both policy and clinical environments. In this commentary, the author relates her family history of maternal morbidity and mortality and advocates for enhancements in collecting data on maternal health outcomes, access to care, understanding of racial disparities, accountability, and listening to patients and families who have been impacted by unsafe maternal care.
Jones CEL, Phipps DL, Ashcroft DM. Saf Sci. 2018;105:114-120.
Under the Safety-I framework, procedural violations in the health care setting might be viewed unfavorably. In the Safety-II framework procedural violations may be seen as necessary modifications within a complex work environment. The authors suggest that applying both frameworks provides deeper understanding of procedural violations in community pharmacies and may facilitate the development of targeted interventions for improving safety.
Patients with serious psychiatric disorders are vulnerable to problems with their care. This commentary describes a cascade of misdiagnoses, errors, and challenges a patient with mental illness faced after being admitted to the hospital following a car accident.
Exploring patient-centered alternatives to traditional malpractice litigation is an ongoing patient safety consideration. Investigators conducted interviews with patients, health care administrators, and malpractice lawyers in New Zealand, where a no-fault scheme has superseded malpractice litigation. Several themes about postincident reconciliation emerged. Patients noted the importance of feeling listened to and the need for prompt apology from providers involved in the adverse event. All stakeholders supported the practice of direct engagement between the treating provider and patient or family as a critical step for reconciliation. Patients and lawyers reported benefits to early involvement from lawyers to support reconciliation. The authors conclude that reconciliation following adverse events requires approaches tailored to individual patient and family needs. An accompanying editorial discusses the importance of transparency for reconciliation and trust.
Quinn GR, Ranum D, Song E, et al. Jt Comm J Qual Patient Saf. 2017;43:508-516.
This analysis of closed malpractice claims sought to characterize the types of errors leading to malpractice claims in patients with cardiovascular disease. Diagnostic errors, especially in patients presenting with nonspecific symptoms but risk factors for cardiovascular disease, were a common cause of claims, implying that improving the accuracy of diagnosing cardiovascular disease may be a promising avenue for reducing morbidity.
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