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March 20, 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
Drennan J, Murphy A, McCarthy VJC, et al. Int J Nurs Stud. 2024;153:104706.
Higher levels of nurse staffing in many clinical settings are associated with improved patient outcomes. Sixteen studies on the effects of nurse staffing in emergency departments (EDs) were identified for this review. Several, but not all, of the studies found that lower nurse staffing was associated with longer wait times, longer time to medications and treatment, and increased risk of cardiac arrest in the ED. Additional longitudinal studies are needed to further investigate nurse staffing in emergency departments.
Gardner C, Rubinfeld IS, Gupta AH, et al. Surg Infect (Larchmt). 2024;25:125-132.
CMS's Hospital-Acquired Condition Reduction Program (HACRP) reduces reimbursements to hospitals with high rates of hospital-associated infections (HAI). This study examines the role of inter-hospital transfer on HAI rates of surgical patients. Results show an increased risk-adjusted rate for HAI in transferred surgical patients compared with non-transferred patients, which in turn results in an increased financial burden on regional hospitals that accept these patients.
Jolliff A, Coller RJ, Kearney H, et al. Appl Clin Inform. 2024;15:45-54.
Improving medication safety at home for children with medical complexity (CMC) is a priority among pediatric care providers. In this study, researchers engaged 16 caregivers and clinicians in a co-design process to develop a mobile health application to improve medication safety for CMC in the home. This process identified several medication safety challenges (e.g., correct dosage/route, timely refills, communicating about medications in and outside of the home), and the co-designers proposed prototype features that could address these concerns.
Jolliff A, Coller RJ, Kearney H, et al. Appl Clin Inform. 2024;15:45-54.
Improving medication safety at home for children with medical complexity (CMC) is a priority among pediatric care providers. In this study, researchers engaged 16 caregivers and clinicians in a co-design process to develop a mobile health application to improve medication safety for CMC in the home. This process identified several medication safety challenges (e.g., correct dosage/route, timely refills, communicating about medications in and outside of the home), and the co-designers proposed prototype features that could address these concerns.
Bodí M, Samper MA, Sirgo G, et al. Int J Med Inform. 2024;184:105352.
Numerous interventions have been promoted to ensure adherence to evidence-based practices and patient safety measures, and yet their use in real-world settings remains inconsistent. This study used random safety audits in the intensive care unit (ICU) to detect errors of omission and deviations from best practices, correcting them in real time when possible. In unadjusted analysis, there were no significant differences in mortality between patients who were included in safety audits and those who were not. However, in adjusted analysis, included patients had lower mortality rates.
Qureshi N, Kroger J, Zangwill KM, et al. J Perinatol. 2024;44:62-70.
Successful implementation of improvement projects is sometimes limited by healthcare provider and staff perception of value. This study describes neonatal intensive care unit (NICU) prescriber perceptions of antibiotic stewardship (AS) before and after the Optimizing Antibiotic Stewardship in California NICUs (OASCN) learning collaborative. Before the collaborative, prescribers reported "a lot" or "some" inappropriate antibiotic prescribing, namely due to fear of bad outcomes and reluctance to change practice. After the collaborative, openness to change prescribing practices increased, but the same challenges still existed.
Zheng Y, Rowell B, Chen Q, et al. JMIR Form Res. 2023;7:e51921.
Pharmacists play an essential role in ensuring the correct medications are ordered and dispensed. Based on feedback from focus groups conducted with pharmacists, this article describes the development of a human-centered artificial intelligence (AI) prototype to improve medication dispensing and verification.
Gardner C, Rubinfeld IS, Gupta AH, et al. Surg Infect (Larchmt). 2024;25:125-132.
CMS's Hospital-Acquired Condition Reduction Program (HACRP) reduces reimbursements to hospitals with high rates of hospital-associated infections (HAI). This study examines the role of inter-hospital transfer on HAI rates of surgical patients. Results show an increased risk-adjusted rate for HAI in transferred surgical patients compared with non-transferred patients, which in turn results in an increased financial burden on regional hospitals that accept these patients.
Ohle R, Savage DW, Caswell J, et al. Emerg Med J. 2024;41:145-150.
Misdiagnosis of acute aortic syndrome (AAS), which includes aortic dissection, can result in serious patient harm or death. Based on a retrospective cohort including 1,299 cases of AAS in Ontario, Canada, between 2003-2018, researchers estimated that the rate of AAS misdiagnosis was 12.5%. Presentation to a non-teaching hospital or non-cardiac emergency department increased the odds of misdiagnosis. Mortality and surgical intervention were similar in missed and non-missed cases of AAS.
Fredheim OMS, Klingenberg E, Lindahl AK. J Palliat Med. 2024;Epub Feb 5.
Patients receiving palliative care differ from other hospitalized patients, as their condition is expected to decline as part of their overall disease progression. As such, adverse events are likely to be different for this population. In this study, the Global Trigger Tool (GTT) was tested for suitability and appropriateness of identifying adverse events in patients receiving palliative care. Of the 26 cases identified by the GTT, 16 were considered part of the patient's disease trajectory or known consequences of treatment. The GTT had poor positive predictive value for adverse events in palliative care.
Riley MS, Etheridge J, Palter V, et al. J Am Coll Surg. 2024;238:206-215.
Operating room (OR) ‘black boxes’ collect audio-video recordings of operative procedures and are increasingly used to assess and improve clinical and team performance. This retrospective study examined 7,243 surgical procedures from seven academic medical centers using an OR black box between August 2020 and January 2022. Researchers found that key elements of the time-out and debrief processes were not routinely discussed, such as relevant imaging, anesthesia concerns, or item counts.
Ralston K, Smith SE, Kerins J, et al. BMJ Open Qual. 2024;13:e002641.
Understanding medical trainees’ experiences with medical errors can offer important learning opportunities. This qualitative study examined 221 patient safety incidents experienced by physician trainees in the United Kingdom. The researchers concluded that incidents could generally be attributed to one of four factors – individual skills, collaboration (e.g., communication, trust), organizational systems, or the training environment – and identified safety-related interventions to improve care.
Schroeck H, Whitty MA, Hatton B, et al. Jt Comm J Qual Patient Saf. 2024;Epub Jan 18.
The use of anesthesia in non-operating room settings, such as MRI suites, presents unique patient safety challenges. This mixed methods study explored role expectations and coordination among anesthesia and non-anesthesia healthcare workers in MRI settings. Based on 67 survey responses and 17 interviews, the researchers identified nuanced differences in role expectations related to crisis management, which could threaten patient safety.
Donnelly LF, Podberesky DJ, Towbin AJ, et al. J Am Coll Radiol. 2024;21:61-69.
Accreditation by organizations such as The Joint Commission (TJC) is intended to improve quality of care and patient safety. This study investigates the costs associated with the TJC requirement, Ongoing Professional Practice Evaluation (OPPE), which supports early detection of provider performance issues. The number of providers subject to OPPE, labor hours, and estimated labor costs were pooled from six large healthcare systems. Annual costs per provider are estimated at $50, extrapolated to $78.54 million for all US providers.
Commentary
Campbell JL. Ga L Rev. 2024;58(2):737-802.
Questions exist as to why practitioners with known performance issues continue to practice and affect patient safety. This article suggests a shift in the process of collecting data on clinician performance from a voluntary process focusing on blame to a required generic record. Accordingly, the process would become more reliable, accountability would be focused on the organization, and the reporting stigma would be removed to enhance reporting of mistakes.
Alsabri M, Eapen D, Sabesan V, et al. Pediatr Emerg Care. 2024;40:58-67.
Medication errors are common in emergency departments, with pediatric patients being especially vulnerable. This systematic review identified six studies of medication errors in pediatric emergency care. The most common error was medication dosing, an ongoing challenge due to children's physiology varying by age and the frequent need to estimate weight. Most errors were insignificant/mild or moderate.
Pasquer A, Ducarroz S, Lifante JC, et al. Patient Saf Surg. 2024;18:5.
Various factors, such as technical and non-technical skills or scheduling, can impact perioperative safety. This systematic review, which included 76 studies, concluded that use of specialized, stable operating room teams and use of specialty-dedicated operating rooms can lead to improved patient outcomes. The authors also note that disruptions, communication failures, and resident involvement can increase the risk of adverse outcomes.
Kell G, Roberts A, Umansky S, et al. J Am Med Inform Assoc. 2024;31:1009-1024.
Clinical decision-making is a complex process requiring consideration of information from multiple sources. This systematic review, including 79 studies, explored areas for improvement with medical question answering (QA) systems, which are designed to answer clinicians’ questions in real time based on current evidence. The authors identified several characteristics that could be used to improve future QA systems, such as providing more robust answers or the use of more complex datasets for system development.
Drennan J, Murphy A, McCarthy VJC, et al. Int J Nurs Stud. 2024;153:104706.
Higher levels of nurse staffing in many clinical settings are associated with improved patient outcomes. Sixteen studies on the effects of nurse staffing in emergency departments (EDs) were identified for this review. Several, but not all, of the studies found that lower nurse staffing was associated with longer wait times, longer time to medications and treatment, and increased risk of cardiac arrest in the ED. Additional longitudinal studies are needed to further investigate nurse staffing in emergency departments.
No results.
Baltimore, MD: US Department of Health and Human Services; 2024.
Data demonstrated that patient safety indicators had either improved or had stable performance before the COVID pandemic, but experienced performance degradation after 2021. Lessons learned are included to enhance the resilience of the health care system for future emergencies, such as the creation of metrics to track workplace safety as a component of quality.
New York, NY: Harper Wave; 2024. ISBN: 9780063293014.
Gender bias is receiving increased attention as a factor in unsafe care. This book examines the history of unequal care for women as experienced through the physiological spectrum. The author draws from clinical experience, patient stories, and the literature to illustrate existing care challenges for women.
Geneva, Switzerland: World Health Organization; 2023. ISBN: 9789240088887.
The Medication Without Harm initiative focuses on the world-wide challenges of safe medication use. This systematic review and accompanying policy brief examine the frequency, severity, and characteristics of medication-related harm across the economic and development spectrum.
Sacramento, CA: Hospital Quality Institute; 2024.
The COVID pandemic posed wide-ranging challenges to both society at large as well as to the health care system, revealing weaknesses and degrading safety achievements. This analysis of California patient safety organization data explores the role of workforce demands during the crisis to affect falls, medication safety, healthcare associated infections, and pressure injuries.
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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