Email Updates
Certain groups of people disproportionately experience avoidable harm in our healthcare system. Over the course of 2023, research posted to AHRQ PSNet has focused on the issue of equity in patient safety. This Year in Review Perspective discusses this body of research, through findings on clinician bias, technological tools, current initiatives directed at improving health equity, and in clinical areas such as obstetrics.
Throughout 2023, the importance patient safety culture and workforce safety culture were recurrent themes among articles on AHRQ PSNet. This Year in Review Perspective for 2023 discusses concepts of psychological safety and employee voice, individual and team factors, and leadership and organizational factors related to safety culture.
This piece discusses the threat that cybersecurity attacks pose to patient safety, as well as ways to prepare and respond to attacks.
John Riggi is the national advisor for cybersecurity and risk at the American Hospital Association. Barbara Pelletreau is a former senior vice president of patient safety for a large healthcare organization. We spoke to them about the risks of cybersecurity to patient safety and how organizations can prepare and respond to cyberattacks.
Summary
Medical errors (all errors in medicine), harmful errors (medical errors that specifically lead to patient harm), and adverse events (harms due to medical care) are leading causes of death and harm in patients in the hospital setting.1,2 Communication failures are a common root cause of sentinel events, which are the most serious harmful errors.3 Minimal research has investigated whether efforts to reduce communication failures across healthcare providers, patients, and families could improve patient safety.4 This intervention sought to determine whether patient safety and communication processes could be improved via a family-centered communication program. Harvard Medical School and Boston Children’s Hospital designed a prospective, multicenter before-and-after intervention study in which families, nurses, and physicians coproduced an intervention to standardize healthcare provider-family communication on ward rounds in hospitals. This approach is also known as family-centered rounds.4
The intervention was conducted on seven pediatric units across the United States and Canada from December 2014 to January 2017. Before the intervention, most sites did not have a formal structure for rounds.4 This intervention, known as Patient and Family Centered I-PASS, was based off of the I-PASS Resident Handoff Study.5 It was adapted for the current study. A team of parents and healthcare professionals adapted the I-PASS framework5 to provide a formal structure for family-centered rounds. I-PASS stands for Illness severity (family reports if child was better, worse, or the same), Patient summary (brief summary of patient presentation, overnight events, plan), Action list (to-dos for the day), Situation awareness and contingency planning (what family and staff should look out for and what might happen), and Synthesis by receiver (family reads back key points of plan for the day, prompted by presenter and supported by nurse as needed).4 In addition to structuring communication on rounds around the I-PASS framework, the intervention sought to engage families in rounds by having them share their questions and concerns first and ensuring providers used simple language instead of medical jargon. The intervention engaged nurses to be present and speak early on rounds and support families. Finally, it involved a written summary of rounds filled out in real time, known as the Rounds Report.
The study team reviewed 3,106 patient admissions (1,574 preintervention and 1,532 postintervention), or a total of 13,171 patient days (6,326 preintervention and 6,845 postintervention) for medical errors, harmful errors, and nonpreventable adverse events.4 After the standardized family-centered rounds intervention was implemented, harmful errors decreased by 38% (20.7 per 1,000 patient days preintervention to 12.9 per 1,000 days postintervention; p=0.01).4 The overall rate of medical errors and nonharmful medical errors did not change.4
The study also had an unexpected decrease in nonpreventable adverse events. They decreased from 12.6 per 1,000 preintervention to 5.2 per 1,000 postintervention (p=0.003).4 This unexpected improvement may be due to improved engagement and communication with families, which prevented some adverse events from occurring in ways not apparent in the normal determination of adverse events.4 The reduction in harmful events occurred without significantly increasing the duration of rounds.4 Additionally, the intervention was found to improve key communication behaviors, like family and nurse engagement on rounds, and several measures of family experience.4
Per the innovator, Patient and Family Centered I-PASS is a novel approach in the patient safety movement. This innovation can be applied in many other settings of care, such as nursing homes and rehabilitation centers. Patient and Family Centered I-PASS has the potential to significantly reduce medical errors.
Innovation Patient Safety Focus
The Patient and Family Centered I-PASS innovation aimed to improve patient safety by improving health literacy, family engagement, and bidirectional structured communication between healthcare providers and patients’ families through the use of the modified I-PASS framework to standardize family-centered rounds.4
Evidence Rating
Resources Used and Skills Needed
- Institutional support: Leadership support for the intervention
- Buy-in from families and the patient’s team of healthcare providers
- Unit physician and nursing champions who can help support implementation and training
- Support from families in sustaining the innovation
- Time and finances to properly train families and the patient’s healthcare team on the intervention. This includes a family orientation via brochures (for families, training on the content in the brochures is conducted by nurse staff), training modules (for healthcare providers), and the review of an implementation guide (for healthcare providers).4
- The implementation of observational tools (including core items and modules on activating and engaging the family and interprofessional team, patient-centered conversation and written information, use of structured communication techniques, and teaching) to ensure intervention adherence and improvement through audit and feedback4
- Disseminate campaign materials to encourage adoption of the intervention4
- Conduct meetings and teleconferences across sites, if the intervention is implemented across multiple sites, to track innovation progress and to address any challenges discovered during implementation4
- Conduct statistical analyses to assess changes in patient safety (medical errors and adverse events) and communication processes4
- Interpretation and translation resources for those who speak languages other than English
Use By Other Organizations
Per the innovator, engaging families in rounds has traditionally been done in the pediatric setting. Understanding where family-centered rounds could fit into the adult care setting has the potential to make a major impact. This innovation has the potential to improve health equity by ensuring standardized, clear communication and a partnership with patients and families.
Developing Organizations
Date First Implemented
This WebM&M describes two cases illustrating several types of Electronic Health Record (EHR) errors, with a common thread of erroneous use of electronic text-generation functionality, such as copy/paste, copy forward, and automatically pulling information from other electronic sources to populate clinical notes. The commentary discusses other EHR-based documentation tools (such as dot phrases), the influence of new documentation guidelines, and the role of artificial intelligence (AI) tools to capture documentation.
This case describes an older adult patient with generalized abdominal pain who was eventually diagnosed with inoperable bowel necrosis. Although she appeared well and had stable vital signs, triage was delayed due to emergency department (ED) crowding, which is usually a result of hospital crowding. She was under-triaged and waited three hours before any diagnostic studies or interventions commenced. Once she was placed on a hallway gurney laboratory and imaging studies proceeded hastily. Catastrophic bowel necrosis was eventually identified, yet she was not moved to a standard ED treatment bed for another 25 minutes. Despite aggressive resuscitation, the surgeon determined that operative intervention was futile, and the patient died a short time later. The commentary highlights how hospital crowding and ED boarding can lead to delayed triage and inefficient ED throughput, which compromises patient safety and summarizes approaches to improving ED triage and throughput.
This case highlights two “never events” involving the same patient. A first-year orthopedic surgery resident was consulted to aspirate fluid from the left ankle of a patient in the intensive care unit. The resident, accompanied by a second resident, approached the wrong patient and inserted the needle into the patient’s right ankle. At this point, a third resident entered the room and stated that it was the incorrect patient. The commentary highlights the importance of a proper time out and approaches to improve communication among all members of the care team.
A 14-year-old girl was admitted to the hospital with a new diagnosis of type 1 diabetes mellitus without ketoacidosis. Before discharge, medications intended for home use were delivered to the patient’s bedside, but the resident physician noticed a discrepancy. An insulin pen and pen needles had been ordered, but an insulin vial and extra insulin syringes were delivered. Neither the patient nor the parents had received education on how to draw up and administer insulin using a vial and syringe. The pharmacy staff reported that the insulin pen was out of stock, so the insulin vial was substituted because it contained the same active ingredient. The insulin product switch was declined, and another pharmacy was contacted to provide the insulin pen, which was delivered to the patient’s bedside the following day. The commentary summarizes the patient safety risks associated with drug shortages, drug interoperability standards, and the importance of clear communication between members of the care team if alternative therapies need to be considered
