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May 1, 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
Marsh KM, Turrentine FE, Jin R, et al. J Am Coll Surg. 2024;238:874-879.
Knowing when judgment errors are more likely to occur can increase surgeons' awareness before, during, and after procedures. This study examined the records of 131 patients with 30-day morbidity or mortality to identify any errors in judgment that may have contributed to harm. Examples of errors in judgment included inappropriate operation, premature discharge, and premature removal of drain. Most errors occurred post-operatively (including after discharge) and in colorectal and hepatobiliary procedures.
McMullan RD, Churruca K, Hibbert P, et al. Int J Qual Health Care. 2024;36:mzae030.
Unprofessional behavior negatively impacts teamwork, safety culture, and patient safety. This study analyzed 1,310 reports of unprofessional behavior across eight Australian hospitals between 2017-2020. The researchers found that three in ten reports indicated a risk to patient safety, such as interruptions, poor handover communication, and a lack of adherence to hospital policy or protocol.
Müller BS, Lüttel D, Schütze D, et al. J Patient Saf. 2024;Epub Mar 18.
Patient safety in ambulatory care settings is receiving increasing attention. This study evaluated an error management and safety climate intervention implemented across 184 ambulatory practices in Germany. The intervention included email newsletters on error management, e-learning modules to improve team engagement, and interdisciplinary workshops to discuss critical incidents. Survey feedback identified significant improvements in safety climate as well as improvements to incident reporting and learning systems.
McMullan RD, Churruca K, Hibbert P, et al. Int J Qual Health Care. 2024;36:mzae030.
Unprofessional behavior negatively impacts teamwork, safety culture, and patient safety. This study analyzed 1,310 reports of unprofessional behavior across eight Australian hospitals between 2017-2020. The researchers found that three in ten reports indicated a risk to patient safety, such as interruptions, poor handover communication, and a lack of adherence to hospital policy or protocol.
Bursch B, Ziv K, Marchese S, et al. Jt Comm J Qual Patient Saf. 2024;Epub Mar 12.
Peer support is a common component of second victim support programs. This study describes second victims' experiences of organizational emotional support before and after introduction of a skilled peer support program (SPSP). Respondents reported that institutional support had increased; they felt like the organization learned from the adverse event to prevent it from recurring.
Ambrose JW, Catchpole K, Evans HL, et al. BMC Health Serv Res. 2024;24:459.
COVID-19 brought unprecedented challenges to healthcare teams. This study describes factors that contributed to or detracted from healthcare team resiliency. Participants reported increased team cohesion and shared responsibility while also describing the environment as a "pressure cooker." There were also difficulties stemming from gaps in knowledge of reassigned staff, for example, pediatric nurses reassigned to adult wards.
Marsh KM, Turrentine FE, Jin R, et al. J Am Coll Surg. 2024;238:874-879.
Knowing when judgment errors are more likely to occur can increase surgeons' awareness before, during, and after procedures. This study examined the records of 131 patients with 30-day morbidity or mortality to identify any errors in judgment that may have contributed to harm. Examples of errors in judgment included inappropriate operation, premature discharge, and premature removal of drain. Most errors occurred post-operatively (including after discharge) and in colorectal and hepatobiliary procedures.
Edfeldt K, Nyholm L, Jangland E, et al. BMC Nurs. 2024;23:233.
Missed nursing care (MNC) is an indicator of poor quality. This study surveyed nursing assistants (NA) and registered nurses (RN) in three surgical wards in Sweden about the types of and factors associated with MNC. The most frequently missed tasks, reported by both RNs and NAs, included not attending interdisciplinary care conferences and not performing ambulation three times per day. Nearly a quarter of RNs and NAs intended to leave within the year. Given the most frequently endorsed reason for missed nursing care is understaffing, and that a quarter of staff intend to leave within the year, interventions aimed at reducing nurse turnover may reduce missed nursing care.
Li L, Badgery-Parker T, Merchant A, et al. BMJ Qual Saf. 2024;Epub Apr 15.
Errors and near misses reported to incident reporting systems (IRS) provide valuable information, but studies have shown errors frequently go unreported. In this study of medication errors in two children hospitals, out of 11,302 prescribing errors identified during audit, only 36 had been reported to the IRS; none of the 2,883 administration errors were reported to the IRS.
Haimi M, Wheeler SQ. JMIR Hum Factors. 2024;11:e50676.
Teletriage is a component of telehealth wherein patients or their families seek advice on their symptoms and whether, and how urgently, they should seek additional care. This article includes a narrative review and interviews with one American nurse and 15 Israeli pediatric physicians who practice teletriage. Despite the differences between provider profession and health care system, the same essential elements of safe teletriage were identified: specialized clinical training, electronic algorithms and protocols, documentation, and clinical call center standards.
Brooks KC, Raffel KE, Chia D, et al. JAMA Intern Med. 2024;Epub Apr 15.
Stigmatizing language in electronic health records (EHR) has been shown to negatively impact the quality of patient care and patient hesitancy to seek future care. This study identified that stigmatizing language (questioning of patient credibility, racial or social class stereotyping, expressions of disapproval toward patients, and descriptions of difficult patients) was more common among Black patients than Asian or white, and more common among patients with housing instability. Further work is needed to explore and mitigate these associations.
Müller BS, Lüttel D, Schütze D, et al. J Patient Saf. 2024;Epub Mar 18.
Patient safety in ambulatory care settings is receiving increasing attention. This study evaluated an error management and safety climate intervention implemented across 184 ambulatory practices in Germany. The intervention included email newsletters on error management, e-learning modules to improve team engagement, and interdisciplinary workshops to discuss critical incidents. Survey feedback identified significant improvements in safety climate as well as improvements to incident reporting and learning systems.
Torzone A, Birely A. Curr Opin Cardiol. 2024;Epub Mar 27.
High reliability organizations can operate in complex, high-risk situations for extended periods without sacrificing safety. This article discusses how high reliability concepts can be applied at pediatric cardiac centers to support safe, high-quality care. The authors highlight the importance of interprofessional collaboration, the role of nurses and advanced practice providers, and fostering psychological safety through hierarchy changes.
Ranasinghe S, Nadeshkumar A, Senadheera S, et al. BMJ Open Qual. 2024;13:e002570.
Preventable adverse events can lead to significant excess costs for patients, caregivers, and healthcare systems. This systematic review of 33 studies identified considerable variability in how the costs associated with medication errors are calculated and highlight the need for a validated, standard method for calculating these costs.
Kiljunen O, Savela R‐M, Välimäki T, et al. Res Nurs Health. 2024;Epub Mar 24.
Concerns about resident safety in nursing homes and residential care settings are not new but, but the COVID-19 pandemic brought these concerns to the fore. This review summarizes the managerial perspective of barriers and facilitators to resident safety in long-term care settings. Physical and human resources, and national regulations and networks emerged as pivotal factors in promoting resident safety. The results demonstrate the importance of organizational, not solely individual, support of resident safety work.
Haimi M, Wheeler SQ. JMIR Hum Factors. 2024;11:e50676.
Teletriage is a component of telehealth wherein patients or their families seek advice on their symptoms and whether, and how urgently, they should seek additional care. This article includes a narrative review and interviews with one American nurse and 15 Israeli pediatric physicians who practice teletriage. Despite the differences between provider profession and health care system, the same essential elements of safe teletriage were identified: specialized clinical training, electronic algorithms and protocols, documentation, and clinical call center standards.
United States Meeting/Conference
The Armstrong Institute Center for Diagnostic Excellence. Johns Hopkins University, Baltimore, MD, May 22, 2024, 9:00 AM-4:00 PM (eastern).
Diagnostic excellence must be tracked to enable and inform lasting improvement. The theme of this annual event is “From Data to Implementation”. The importance of diagnostic excellence measurement and enhancing equity in measurement processes are amongst the topics to be covered.
United States Meeting/Conference
May 23, 2024, 3:30 – 4:30 PM (eastern).
An understanding of organizational safety culture is fundamental to driving improvement. This webinar will highlight how the Indiana Hospital Association (IHA) used AHRQ’s Surveys on Patient Safety Culture® (SOPS®) Hospital Survey and Workplace Safety Supplemental Item Set to examine patient safety culture and workplace safety in 41 Indiana hospitals. Presenters will discuss the survey results, how SOPS resources were used, and their focus on initiatives to address workplace safety, including burnout.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute Care. 2024;29(8):1-4.
A multitude of latent and active failures typically contribute to harmful medication errors in hospitals. This article examines a prolonged intravenous medication administration error and describes “holes in the Swiss cheese” that enabled the failure. Recommendations for improvement discussed in this article include daily review of medications, look-alike medication management, and infusion line verification.
Book/Report
Geneva, Switzerland: World Health Organization; April 2024. ISBN: 9789240093249.
Patients have the right to expect safe, equitable, high-quality care. This 10-point charter serves to describe the establishment of a broad-based global action plan that enables foundational work to be done in support of patient safety. The right to dignity, competent clinicians, and medical record access are amongst the required elements of the charter.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Eric Signoff, MD, Noelle Boctor, MD, and David K. Barnes, MD, FACE |
A 61-year-old patient presented to the emergency department (ED) complaining of weakness with findings of shuffling gait, slurred speech, delayed response to questions, and inability to concentrate or make eye contact. A stroke alert was activated and a neurosurgeon evaluated the patient via teleconsult. There was no intracranial hemorrhage identified on non-contrast computed tomography (CT) of the head and the neurosurgeon recommended administering Tenecteplase (TNK). Thirty minutes after TNK administration, laboratory tests showed that the patient’s alcohol level was 433 mg/dL, a potentially fatal level. The patient was admitted to the intensive care unit (ICU) for close monitoring. A repeat CT scan was performed and revealed a new subdural hemorrhage. The neurosurgeon was updated, conservative treatment was recommended, and the patient recovered slowly. The commentary highlights how “stroke chameleons,” “stroke mimics,” and biases contribute to stroke misdiagnosis and strategies to identify “stroke mimics” and improve stroke diagnosis.
WebM&M Cases
Spotlight Case
Christian Bohringer, MBBS, Manuel Fierro, MD, and Sandhya Venugopal, MD |
A 77-year-old man was admitted for coronary artery bypass graft surgery with aortic valve replacement. The operation went smoothly but the patient went into atrial fibrillation with hypotension during removal of the venous cannula. The patient was shocked at 10 Joules but did not convert to sinus rhythm; the surgeon requested 20 Joules synchronized cardioversion, after which the patient went into ventricular fibrillation and was immediately and successfully defibrillated with 20 Joules. While the patient was being transferred to his gurney, the operating room team noticed that the electrocardiogram cable that enables synchronized cardioversion was only connected into the anesthesia monitor and was never connected to the patient’s defibrillator. The commentary discusses the risks of unsynchronized shocks or pacing, the role of standardized processes to ensure that operating room equipment is prepared and set-up correctly, and the importance of operating room team preparation to urgently address life threatening complications
WebM&M Cases
Anita Singh, MD and Cecilia Huang, MD |
An 82-year-old woman presented to the emergency department for evaluation of “altered mental status” after falling down 5 step-stairs at home. She had a Glasgow Coma Score of 11 (indicating decreased alertness) on arrival. Computed tomography (CT) of the head revealed a right thalamic hemorrhage. She was admitted to the Vascular Neurology service. Overnight, the patient developed atrial fibrillation with rapid ventricular rate (RVR), which required medications for rate control. The patient failed her swallow evaluation by speech therapy; therefore, a nasogastric (NG) tube was inserted through her right nostril, without difficulty or complications, to administer oral medications. A chest radiograph was obtained to verify placement, but the resident physician did not review the images. During nursing shift change, the incoming nurse was told that the NG tube was ready for use. A tablet of metoprolol 25 mg was crushed by the nurse, mixed with water, and administered through the NG tube. A few minutes after administration, the patient was found to be somnolent and hypoxemic, with oxygen saturation around 80%, requiring supplemental oxygen via non-rebreather mask. Chest radiography showed that the NG tube was in the right lung. The commentary underscores the importance of confirming proper placement of NG tubes before administering feedings, fluids or medications and strategies to reduce the risk of tube placement errors.
This Month’s Perspectives
Interview
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCT |
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCT, is the Director of Nursing Programs at the American Nurses Association and Adjunct Professor at the University of Maryland School of Nursing and the Frances Payne Bolton School of Nursing at Case Western Reserve University. We spoke to her about patient safety amid nursing workforce challenges.
Perspective
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD |
This piece focuses on changes in the nursing workforce over recent years, including nursing shortages. Patient safety challenges may arise from these workforce challenges, but those challenges can also be mitigated.
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