Email Updates
March 6, 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
Liu SK, Bourgeois FC, Dong J, et al. Diagnosis (Berl). 2024;11:63-72.
Patient feedback on diagnostic errors may improve the quality and safety of care. As part of the larger OurDx study, this analysis examined patient feedback on what went well with the diagnostic process. Results mirrored those of studies on diagnostic errors, stating feeling heard, appreciated, and timely communication contributed to a good diagnostic process.
Satterwhite S, Nguyen M-LT, Honcharov V, et al. J Gen Intern Med. 2024;Epub Feb 15.
Inadequate resource allocation (e.g., time, clinician workforce) can threaten patient safety. Twenty-five semi-structured interviews with primary care providers explored near-miss events where taking extra time during patient visits can avoid a more serious event. These near-miss events generally occurred in five clinical scenarios – high-risk social situations (e.g., pediatric patient requiring a home safety assessment), high-risk medication regimens requiring patient education, high acuity conditions, interactions of physical and mental health, and investigating subtle clinical suspicions or red flags. The authors outline structural and mitigating interventions to address time scarcity in care delivery.
Glarcher M, Vaismoradi M. J Adv Nurs. 2024;Epub Feb 17.
Advanced practice nurses (APN) such as nurse practitioners, certified registered nurse anesthetists, and clinical nurse specialists can improve patient outcomes and quality of life. In this review, studies found that patients receiving care from either APNs or physicians experienced similar outcomes, and APNs were critical in advancing patient safety culture mainly focusing on interdisciplinary teamwork.
Vandenberg AE, Hwang U, Das S, et al. J Am Geriatr Soc. 2024;Epub Jan 23.
The Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) medication safety program targets potentially inappropriate medication (PIM) prescribing among older adults discharged from the emergency department (ED). This study examined two implementation approaches to scaling up EQUIPPED at four EDs (one ‘traditional’ site and three ‘hub-and-spoke’ sites). After implementation, PIM prescribing declined significantly at all four EDs, indicating that the hub-and-spoke model can offer a new and effective approach to spread a scaled-up EQUIPPED program.
Satterwhite S, Nguyen M-LT, Honcharov V, et al. J Gen Intern Med. 2024;Epub Feb 15.
Inadequate resource allocation (e.g., time, clinician workforce) can threaten patient safety. Twenty-five semi-structured interviews with primary care providers explored near-miss events where taking extra time during patient visits can avoid a more serious event. These near-miss events generally occurred in five clinical scenarios – high-risk social situations (e.g., pediatric patient requiring a home safety assessment), high-risk medication regimens requiring patient education, high acuity conditions, interactions of physical and mental health, and investigating subtle clinical suspicions or red flags. The authors outline structural and mitigating interventions to address time scarcity in care delivery.
Villafranca A, Fast I, Turick M, et al. Can J Anaesth. 2024;71:490-502.
Disruptive and unprofessional behavior continues to be a common problem in healthcare settings. This survey of clinicians from seven countries highlights how disruptive behavior can threaten patient safety in perioperative settings, such as unnecessary changes in medical care and poor team communication.
Yang C, Coney L, Mohanraj D, et al. AMIA Annu Symp Proc. 2023;2023:774-783.
Implicit biases can compromise decision making and lead to inequitable care delivery and poor patient outcomes. In this study, researchers conducted seven participatory co-design workshops to identify new ideas for patient-centered interventions to mitigate implicit bias in patient-provider interactions in primary care. Participants – who had firsthand experiences of discrimination in primary care settings – identified four types of solutions: accountability measures (e.g., recording interactions, use of third-party patient advocate), real-time correction (e.g., patient use of ‘panic buttons’ alerting medical staff to an unsafe interaction), patient resources (e.g., communication aids), and provider resources (e.g., training).
Gudelunas MK, Lipnick M, Hendrickson C, et al. Anesth Analg. 2023;138:552-561.
Pulse oximeters have been implicated in underdiagnosis of hypoxemia in patients with darker skin. This study compared matched pulse oximeter readings and arterial oxygen saturation during stable hypoxemia of patients with light, medium, and dark skin. In medium and dark subjects, bias (error) increased with low perfusion and degree of hypoxemia, with a combined frequency of missed diagnosis of hypoxemia for patients with dark skin of 21.1%.
Sutherland A, Phipps DL, Gill A, et al. J Patient Saf. 2024;20:7-15.
Preventing medication errors is an ongoing patient safety challenge. This qualitative study explored how sociotechnical systems contribute to adverse drug events (ADEs) in pediatric patients. Several contributory factors were identified, including resource limitations, cognitive demands, and workarounds.
Prothero MM, Huefner K, Sorhus M. J Nurs Adm. 2024;54:10-15.
Effective leadership behaviors are essential to promote psychological safety and speaking-up behaviors. This cross-sectional study with 304 nurse leaders identified positive attitudes regarding medical error reporting and underscores the importance of nurse leaders in fostering a just culture.
Ron D, Gunn CM, Havidich JE, et al. Jt Comm J Qual Patient Saf. 2024;Epub Jan 18.
Communication breakdowns between clinicians can detract from safe care. This cross-sectional study including 265 surgical patients and 249 providers (primary care, anesthesia, and surgeons) identified several communication and coordination challenges in preoperative care. Although nearly all patients (96%) reported that preoperative communication between providers is important, the majority of inpatient providers reported infrequent communications with each other and with primary care providers.
Vandenberg AE, Hwang U, Das S, et al. J Am Geriatr Soc. 2024;Epub Jan 23.
The Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) medication safety program targets potentially inappropriate medication (PIM) prescribing among older adults discharged from the emergency department (ED). This study examined two implementation approaches to scaling up EQUIPPED at four EDs (one ‘traditional’ site and three ‘hub-and-spoke’ sites). After implementation, PIM prescribing declined significantly at all four EDs, indicating that the hub-and-spoke model can offer a new and effective approach to spread a scaled-up EQUIPPED program.
Marks CM, Wolfe RE, Grossman SA. Intern Emerg Med. 2024;Epub Feb 19.
At the beginning of the COVID-19 pandemic, many hospitals restricted visitors to prevent the spread of the virus. This study analyzed five types of medical error that could have been prevented if the patient's support person had been present under pre- and post-COVID visitation policies. Unlike other research, this study did not find any statistically significant differences in errors between the pre- and post-COVID eras in emergency department patients.
Liu SK, Bourgeois FC, Dong J, et al. Diagnosis (Berl). 2024;11:63-72.
Patient feedback on diagnostic errors may improve the quality and safety of care. As part of the larger OurDx study, this analysis examined patient feedback on what went well with the diagnostic process. Results mirrored those of studies on diagnostic errors, stating feeling heard, appreciated, and timely communication contributed to a good diagnostic process.
Call RC, Espiritu SG, Barrows DA. Int Anesthesiol Clin. 2024;62:9-15.
The Safety-II principle focuses on learning from what goes right in the healthcare system. The authors posit that provider adaptability, not inflexible policies, can improve safety in times of uncertainty. They describe several systems-based theories (e.g., high-reliability, crew resource management) that can be applied to healthcare delivery.
Ratwani RM, Bates DW, Classen DC. JAMA Health Forum. 2024;5:e235514.
Artificial intelligence (AI) is being widely discussed as a tool that will prevent failures in decision making that lead to patient harm. This commentary submits three approaches to ensuring AI is developed and installed in a safe and reliable manner that complements United States government AI quality efforts: guideline development and adherence, system patient safety threat monitoring, and process development for tracking AI as a contributor to patient safety events.
Launder D, Penney G. J Contin Crisis Manag. 2023;31:862-876.
Medical emergencies are high-risk situations requiring rapid decision making. This article describes the Situation, Context, Decision, Plan, Act Review (SPAR-CD) framework developed in urban fire services which can be applied in other high-risk situations such as healthcare. This framework supports approaching complex situations, making informed decisions, and improving processes over time through continuous learning and adaptation.
Glarcher M, Vaismoradi M. J Adv Nurs. 2024;Epub Feb 17.
Advanced practice nurses (APN) such as nurse practitioners, certified registered nurse anesthetists, and clinical nurse specialists can improve patient outcomes and quality of life. In this review, studies found that patients receiving care from either APNs or physicians experienced similar outcomes, and APNs were critical in advancing patient safety culture mainly focusing on interdisciplinary teamwork.
Skegg E, McElroy C, Mudgway M, et al. J Nurs Scholarsh. 2023;55:1179-1188.
Debriefing is a core strategy to foster learning opportunities and reduce future errors. This systematic review explored the barriers and facilitators of effective implementation of surgical debriefing. Findings highlight the importance of leadership commitment, integration with existing quality and safety processes, and closed-loop feedback to operating room team members.
Alqarrain Y, Roudsari A, Courtney KL, et al. Comput Inform Nurs. 2024;Epub Feb 20.
Situational awareness is the ability to perceive, understand, and respond to a situation. This systematic review identified nine studies aimed at improving nurses' situational awareness and, therefore, patient safety. Intervention types included electronic health record (EHR) dashboards, communication, and structured nursing assessments. The evidence that EHR dashboards improve situational awareness was weak, and future research should utilize a situational awareness model in development of dashboards.
International Meeting/Conference
Institute for Healthcare Improvement. March 14, 2024: 11:00 AM – 12:00 PM (eastern).
Diagnostic safety is core to care without harm. This webinar aligns with the 2024 Patient Safety Awareness Week theme of diagnostic excellence. A panel of experts representing advocacy, academic and research entities will participate.
Newspaper/Magazine Article
Wells K. Health Shots. KFF News and Michigan Public. February 22, 2024.
Mandatory staffing ratios are a controversial strategy for improving patient safety. This story presents one family member’s effort to understand his wife’s death from sepsis in the context of staffing challenges during the COVID-19 pandemic that limited nurse ability to provide safe care.
Blackstock U. New York, NY: Viking; 2024. ISBN: 9780593491287.
The history of systemic racism is emerging to motivate health care equity and safety efforts. This memoir draws from a Black woman's experience as both a clinician and a patient to examine failures due to embedded system flaws that enable unequal care while serving as a call for change.
Newspaper/Magazine Article
Pharmacy Practice News; February 2024: Suppl 1-12.
The medication process has multiple steps in it that can open the door to mistakes. This article reviews different types of errors submitted to the Institute for Safe Medication Practices reporting program in 2023. The piece discusses medications involved, error mitigation strategies, and the role of teamwork in medication safety improvement.
This Month’s WebM&Ms
WebM&M Cases
Caitlin Loseth, MD |
A 60-year-old woman with a history of cirrhosis arrived at the emergency department (ED) with an open right ankle injury and moderate blood loss after falling at home. A tourniquet was placed and her initial point-of-care hemoglobin was 7 mg/dl, so a “massive transfusion protocol” was initiated. The patient progressed to cardiac arrest and chest tubes were placed on both sides of the chest. After return of spontaneous circulation, fluid was identified in the abdomen, so the patient was immediately transferred to the operating room (OR) for exploratory laparotomy. Bleeding was noted to be coming from lacerations in the lateral chest wall and in the right lateral aspect of the liver, which was enlarged and visibly cirrhotic with splenomegaly. Multiple packing maneuvers were attempted but definitive hemorrhage control could not be obtained. This commentary highlights the challenges in managing blunt trauma in actively bleeding patients with a history of cirrhosis and the importance of frameworks and protocols (e.g., Advanced Trauma Life Support [ATLS], Massive Transfusion Protocol [MTP]) to protect against misadventures in the trauma bay.
WebM&M Cases
Spotlight Case
Claudia López, MD and Véronique Taché, MD |
A patient who was 39-weeks pregnant presented to the hospital in active labor, admitted to the Labor and Delivery unit and confirmed to have a full-term singleton fetus in vertex presentation. After several hours on oxytocin, the fetal head was still relatively high and the fetal heart rhythm suggested hypoxemia. The physician attempted delivery using a vacuum, but ultimately performed an emergency cesarean delivery of a healthy newborn. The procedure was complicated by the need to extend the lower uterine segment incision bilaterally for safe extraction of the fetus. The operator’s note described post-delivery repair of the right uterine incision but did not comment on the left side. Following the delivery, the patient was noted to be hypotensive and tachycardic and went into cardiac arrest. Another physician opened the patient’s incision and found nearly three liters of blood had collected in her abdomen, apparently due to complete transection of the left uterine artery. The commentary highlights the risk factors for obstetric hemorrhage, summarizes standardized risk assessments used to alert for potential obstetric hemorrhage and use of obstetric simulation training to improve team communication and performance.
WebM&M Cases
Spotlight Case
James A. Bourgeois, OD, MD and Glen Xiong, MD |
An 18-year-old woman with no significant past medical history was admitted to a community hospital for evaluation and treatment of acute psychosis with paranoid delusions and started on an antipsychotic medication. On hospital day 7, the nurse practitioner learned from the patient’s father that there was a family history of systemic lupus erythematosus (SLE) and suggested that the patient be evaluated for lupus. Laboratory tests indicated borderline pancytopenia, an elevated antinuclear antibody (ANA), and abnormally elevated anti-double-stranded DNA, but these laboratory tests were not evaluated until 2-3 days after discharge and the patient was never referred for further evaluation. The commentary discusses the clinical manifestations of a primarily psychiatric presentation of SLE, the importance of family history when evaluating patients with psychotic presentations, and the need for clear communication between medical specialists to ensure safe, high-quality care.
This Month’s Perspectives
Interview
Barbara Pelletreau, RN; John Riggi |
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.
Interview
Patrick Tighe, MD, MS |
Patrick Tighe, MD, MS, is a practicing anesthesiologist at University of Florida Health (UF Health) and the executive director of UF Health’s Quality and Patient Safety Initiative. We spoke to him about the current and potential impacts of artificial intelligence (AI) on patient safety as well as challenges to successful implementation.
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