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February 14, 2024 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports, and more. Past issues of the PSNet Weekly Update are available to browse. WebM&M presents current and past monthly issues of Cases & Commentaries and Perspectives on Safety.
This Week’s Featured Articles
Bakker T, Klopotowska JE, Dongelmans DA, et al. Lancet. 2024;403:439-449.
Alert fatigue occurs when clinical decision support systems (CDSS) produce numerous low-relevance alerts, leading to high override rates and the risk of missing relevant alerts. In this study, alerts for high-risk drug-drug interactions (DDI) were tailored to the intensive care unit. The tailored alerts led to a 12% decrease in high-risk DDI administrations.
Bokka L, Ciuffo F, Clapper TC. J Patient Saf. 2024;20:110-118.
Simulation provides a safe environment to learn new skills or identify medical errors. This system review highlights 20 studies on healthcare simulation to characterize types of errors identified. Errors were categorized into errors of commission, errors of omission, systems-related, or communication-related. All 13 studies that identified systems-related errors were conducted in situ, underscoring the importance of simulations on actual clinical units.
Naseralallah L, Stewart D, Price M, et al. Int J Clin Pharm. 2023;45:1359-1377.
Medication errors in ambulatory care settings present unique patient safety challenges. This systematic review explored the prevalence of medication errors in outpatient and ambulatory care settings. Findings indicate that prescribing errors (e.g., dosing errors) are the most common type of medication error and are often attributed to latent factors, such as knowledge gaps.
Cosby K, Yang D, Fineberg HV. NEJM Evid. 2024;3:EVIDra2300232.
Assessing diagnostic performance to reduce diagnostic errors requires a shared understanding of the diagnostic purpose. This article describes the various ways evidence is collected based on the diagnostic purpose: optimal clinical care (e.g., usefulness of testing), population screening and disease surveillance, quality improvement, and regulation (e.g., of machine learning). This is the first in a series of articles that will further elaborate on these diagnostic purposes.
Boxley C, Fujimoto M, Ratwani RM, et al. Sci Rep. 2023;13:18354.
Patient safety reporting systems offer a way to collect rich data on types of errors. This study measured the performance of three natural language processing (NLP) models to identify important medication safety patterns and trends from 3,861 patient safety reports. These and other machine learning models (e.g., ChatGPT) have the potential to improve how medication-related patient safety events are categorized and monitored that can impact patient medication safety.
Luckraj N, Strazzari R, Coiera E, et al. Stud Health Technol Inform. 2024;310:514-518.
Clinical decision support systems (CDSS) are used in a multitude of healthcare settings to support safe, high-quality patient care. Using standardized patient vignettes, this study found that a new CDSS to support telephone triage used by nurses in Australia was accurate and at least as safe as the CDSS currently being used.
Gregory EF, Johnson GT, Barreto A, et al. Ann Fam Med. 2024;22:31-36.
Women of color often experience poor quality or unsafe maternal care. This qualitative study included non-Hispanic Black birthing people on Medicaid who experienced preterm birth. Thematic analyses identified three priority areas to improve patient experience and safety during preterm birth – improved communication about intrapartum procedures, mitigated psychological consequences through opportunities to share birth experiences and improved communication about future pregnancy risks (or lack thereof).
Coope SA, Augustin S. Br J Community Nurs. 2023;28:604-610.
Interventions to improve quality and safety benefit from local champions to implement and sustain the project. This study evaluated the impact of quality and safe care champions (QSCCs) on improving the quality of care in a community setting. Results indicate that QSCCs can play a role in improving patient care quality and safety, but they require stable leadership, dedicated time and resources, and professional support from QA leads.
Bogaert K, Regge MD, Vermassen F, et al. Int J Qual Health Care. 2024;36:mzad116.
External hospital accreditation can result in improve quality and safety, but may also result in inefficiencies or mandate practices in conflict with the hospital’s values. This paper details one hospital’s process of developing an internal quality model in place of external accreditation. A patient advisory council, staff, leadership, and clinicians participated in a multi-phase process which ultimately resulted in eight broad themes including patient-centered and accessible care and proper handling of patient incidents.
Péculo-Carrasco J-A, Rodríguez-Ruiz H-J, Puerta-Córdoba A, et al. Int Emerg Nurs. 2023;72:101383.
Care provided by emergency medical services (EMS) personnel presents unique patient safety challenges. This cross-sectional study including 1400 witnesses of care provided by emergency medical services in Spain found that perceptions of safety decreased when witnesses reported a safety incident or when the care was provided in a public space.
King L, Belan I, Clark RA, et al. Jt Comm J Qual Patient Saf. 2024;50:116-126.
Patient and caregiver engagement furthers the delivery of safe, high-quality healthcare. This mixed methods study at one Australian hospital found that exposure to education materials increased patient and visitors’ awareness of clinical deterioration and their role in reporting it.
Brown CE, Marshall AR, Cueva KL, et al. JAMA Netw Open. 2024;7:e2352818.
Anti-Black racism not only impacts the care a patient receives, but whether they seek care in the future. In this study, participating physicians responded to clinical scenarios in which anti-Black racism was a patient concern, describing prior similar experiences and offering potential strategies to address anti-Black racism. Validation and mutual understanding were identified as potential strategies. Significantly, only two of the 21 participants mentioned apologizing as an important step in taking responsibility.
Naseralallah L, Stewart D, Price M, et al. Int J Clin Pharm. 2023;45:1359-1377.
Medication errors in ambulatory care settings present unique patient safety challenges. This systematic review explored the prevalence of medication errors in outpatient and ambulatory care settings. Findings indicate that prescribing errors (e.g., dosing errors) are the most common type of medication error and are often attributed to latent factors, such as knowledge gaps.
Sheth S, Bialostozky M, Hollenbach K, et al. Pediatrics. 2024;153:e2023061964.
Medication reconciliation has the potential to reduce medication errors during transitions of care. This study used educational and electronic health record-based interventions to increase completed medication reconciliation in one health systems’ pediatric emergency department (ED) and urgent care (UC) settings. Post-implementation, completed medication reconciliation in UCs increased from 25% to 82% within four months; in the pediatric ED, completed reviews increased from 26% to 64% within 18 months.
Bakker T, Klopotowska JE, Dongelmans DA, et al. Lancet. 2024;403:439-449.
Alert fatigue occurs when clinical decision support systems (CDSS) produce numerous low-relevance alerts, leading to high override rates and the risk of missing relevant alerts. In this study, alerts for high-risk drug-drug interactions (DDI) were tailored to the intensive care unit. The tailored alerts led to a 12% decrease in high-risk DDI administrations.
Commentary
Speth J. AORN J. 2023;118:380-389.
Nurses play a primary, yet complex, role in medication administration. This commentary summarizes advice supporting safe medication nursing practice. The author summarizes instruction on a range of practices such as storage, labeling, and preparation.
Cosby K, Yang D, Fineberg HV. NEJM Evid. 2024;3:EVIDra2300232.
Assessing diagnostic performance to reduce diagnostic errors requires a shared understanding of the diagnostic purpose. This article describes the various ways evidence is collected based on the diagnostic purpose: optimal clinical care (e.g., usefulness of testing), population screening and disease surveillance, quality improvement, and regulation (e.g., of machine learning). This is the first in a series of articles that will further elaborate on these diagnostic purposes.
Olesen AE, Juhl MH, Deilkås ET, et al. BMC Prim Care. 2024;25:37.
The Safety Attitudes Questionnaire (SAQ) is used to assess patient safety attitudes in various healthcare settings. This systematic review including 43 studies concluded that the SAQ is valid for use in primary care settings but should be further validated for use in specific primary care settings (e.g., out-of-hours clinics, health centers).
Sturmberg JP, Gainsford L, Goodwin N, et al. J Eval Clin Pract. 2024.
Nursing homes must balance resident needs and external pressures which threaten patient safety. This scoping review including 38 articles identified 29 systemic issues faced by nursing homes, including regulatory issues and resident and staff satisfaction.
Bokka L, Ciuffo F, Clapper TC. J Patient Saf. 2024;20:110-118.
Simulation provides a safe environment to learn new skills or identify medical errors. This system review highlights 20 studies on healthcare simulation to characterize types of errors identified. Errors were categorized into errors of commission, errors of omission, systems-related, or communication-related. All 13 studies that identified systems-related errors were conducted in situ, underscoring the importance of simulations on actual clinical units.
United States Meeting/Conference
Hospital Quality Institute. March 12, 2024, Noon - 1:00 PM (eastern).
Older adult patients require approaches that intersect across their social and medical care needs to limit occurrences of harm due to abuse or medical error. This webinar highlights the role of caregivers and clinicians to develop and embrace a comprehensive strategy to safe geriatric care.
WHO Patient Safety Flagship. Geneva; World Health Organization; December 2023. ISBN: 9789240081987.
Patients and families are important, yet underutilized, partners in safety improvement. This publication spotlights actions that various types of organizations and leaders can take to develop and establish strategies that effectively engage patients and families in medical error reduction.
Newspaper/Magazine Article
McFarling UL. STAT. February 2, 2024.
Unequal care has been hardwired into the health system through the persistent implicit presence of personal and algorithmic biases. This news story summarizes regulation activities to address known weaknesses in pulse oximetry and its ability to accurately record information on darker skin.
Dorset, UK: Health Services Safety Investigations Body; November 2023.
Portable infusion pumps deliver palliative medication support in a variety of care environments. This investigation report discusses a case where issues associated with alert receipt, pump maintenance, and medication administration resulted in patient harm when medication delivery problems went unrecognized. Recommendations drawn from the case review are directed toward device manufacturers to improve alerting and care providers on better use and response to alerts.
Newspaper/Magazine Article
Topol EJ. Science. 2024;383:eadn9602.
Artificial intelligence (AI) is being touted as an innovation for enhancing diagnostic reliability. This commentary summarizes the potential improvements and challenges associated with clinician use of AI as a diagnostic tool at the care interface.
This Month’s WebM&Ms
WebM&M Cases
Christian Bohringer, MBBS and Linda Vo, MD |
A 47-year-old obese man with hypertension fell and suffered a cervical spine (C5/C6) fracture. He was scheduled for urgent anterior cervical decompression and fusion and was transferred to the operating room (OR) where general anesthesia was induced. During the procedure, his expired tidal volume decreased from 560 ml to about 330 ml. He was manually ventilated through the endotracheal tube, which proved very difficult. An urgent chest X-ray did not reveal any pneumothorax. The Black Belt cervical retractor was released by the surgeon resulting in complete resolution of the airway obstruction. The commentary highlights the importance of vigilant monitoring and good communication to identify and respond to life-threatening events and describes approaches to improve crisis management during anesthesia events.
WebM&M Cases
Timothy Do, BS and Fiona J Scott, MD, MPH, MS, MHI |
A 32-year-old woman was admitted to the hospital for endoscopic retrograde cholangiopancreatography (ERCP) under monitored anesthesia care (MAC). As the endoscope was advanced into the stomach, the patient vomited. She was immediately turned supine but copious vomitus obstructed the suction catheter. The patient started to decompensate with decreasing oxygen saturation. The anesthesia team attempted to secure the airway by endotracheal intubation but was unable to place a tube due to poor view and vomitus. The patient went into cardiac arrest and ultimately passed away. The commentary discusses safety considerations for ERCP under MAC, weighing the risks and benefits of MAC versus general anesthesia, and airway management during emergencies.
WebM&M Cases
Zachary Chaffin, MD |
A 9-year-old girl with cerebral palsy and epilepsy presented to the emergency department (ED) for increasing frequency of seizures lasting about 5 minutes, and developed hypoxic respiratory failure requiring endotracheal intubation, sedation, and mechanical ventilation. The pediatric neurology team ordered further testing, most of which had to be sent to an external laboratory and the results returned intermittently over several weeks. Several days into the hospital stay, acetylcholine receptor antibody test results returned markedly elevated at 302 nmol/L (normal is <0.5 nmol/L), which is concerning for myasthenia gravis. The laboratory finding that established this diagnosis was available in the electronic health record (EHR), but it was invisible to multiple teams of providers across multiple phases of care due to issues related to the EHR itself, challenges in clinical reasoning, and the workflow around transitions of care. The commentary highlights strategies to improve EHR systems to prevent diagnostic delays and care coordination for children with complex, chronic medical conditions
This Month’s Perspectives
Interview
Monika Haugstetter, MHA, MSN, RN, CPHQ; Stephen Hines, PhD |
Monika Haugstetter, MHA, MSN, RN, CPHQ, is a Health Science Administrator with AHRQ, leading AHRQ’s TeamSTEPPS® initiative. Stephen Hines, PhD, is a Senior Research Scientist at the Arbor Research Collaborative for Health. While at Abt Associates, he co-led the TeamSTEPPS 3.0 revisions in collaboration with AHRQ. We spoke with Monika and Stephen about the newly released TeamSTEPPS 3.0 curriculum.
Perspective
Monika Haugstetter, MHA, MSN, RN, CPHQ; Stephen Hines, PhD; Zoe Sousane, BS; Sarah Mossburg, RN, PhD |
This piece discusses the impact of AHRQ’s TeamSTEPPS training curriculum on patient safety and highlights updates made to the curriculum in 2023 with the launch of TeamSTEPPS 3.0.
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