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May 22, 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
Estrada LV, Barcelona V, Dhingra L, et al. JAMA Netw Open. 2024;7(5):e249312.
Systemic racism and discrimination negatively impact the health of historically marginalized people. In this cross-sectional study of nursing home (NH) residents with severe cognitive impairment, historically marginalized residents had greater incidence of potentially avoidable hospitalizations compared to their white counterparts. Not only did the study identify racial and ethnic disparities at the national level, but also at the individual NH level.
Mamede S, Zandbergen A, de Carvalho-Filho MA, et al. BMJ Qual Saf. 2024;33(9):563-572.
Anchoring bias occurs when a physician relies on their initial diagnostic impression despite subsequent information to the contrary. This study assessed the influence of disease knowledge on susceptibility to anchoring bias. In simulated case studies, physicians with higher disease knowledge were less likely than lower knowledge physicians to be biased by salient distracting features (e.g., patient presenting problem description with or without mention of family history of unrelated disease).
Valkonen V, Saano S, Haatainen K, et al. J Patient Saf. 2024;20(4):259-266.
Voluntary incident reporting data can provide unique insights into errors and opportunities to improve patient safety. This study used an enhanced free-text search method to identify the medication error (ME) reports involving substances commonly involved in medication errors (e.g., oxycodone, Warfarin). This approach increased the number of identified ME reports involving the specified medications and identified additional findings, such as inadequate pain management and duplicate prescriptions.
Valkonen V, Saano S, Haatainen K, et al. J Patient Saf. 2024;20(4):259-266.
Voluntary incident reporting data can provide unique insights into errors and opportunities to improve patient safety. This study used an enhanced free-text search method to identify the medication error (ME) reports involving substances commonly involved in medication errors (e.g., oxycodone, Warfarin). This approach increased the number of identified ME reports involving the specified medications and identified additional findings, such as inadequate pain management and duplicate prescriptions.
Sinnott C, Alboksmaty A, Moxey JM, et al. Br J Gen Pract. 2024;74(742):e339-e346.
Operational failures (e.g., distractions, situational constraints) can impact the delivery of safe, high-quality healthcare. This study, including general practitioners and patients in the UK National Health Service (NHS), used a modified Delphi process to prioritize operational failures in general practice. Participants identified several areas for improvement, including missing test results and inaccuracies in medical records.
Jaakkola M, Lemmetty S, Collin K, et al. Learn Org. 2024;31(3):337-357.
Organizational learning is a continuous process of integrating data and knowledge to ensure improvement. This qualitative study focuses on the starting points and presuppositions of organizational learning within a surgical department. Starting points for individual learning were informal and based on day-to-day work (e.g., solving a specific problem) and organizational learning encompassed more formal and intentional practices. Factors presupposing and framing the learning process can be divided into four categories: leadership and roles, practices and resources, collaboration and climate, and motivation and activity.
Abboudi E, Baron SW, Goriacko P, et al. Am J Health Syst Pharm. 2024;81(10):361-369.
Smart pump dose error reduction systems (DERS) alert users to unsafe medication administration orders. This article describes a performance improvement project to increase utilization of smart pump DERS technology and decrease manual order entry, which is vulnerable to human errors. Use of DERS increased from 77% of administered IV medications to 83%. The most effective intervention was adding a DERS problem reporting tool to the medication administration record.
Estrada LV, Barcelona V, Dhingra L, et al. JAMA Netw Open. 2024;7(5):e249312.
Systemic racism and discrimination negatively impact the health of historically marginalized people. In this cross-sectional study of nursing home (NH) residents with severe cognitive impairment, historically marginalized residents had greater incidence of potentially avoidable hospitalizations compared to their white counterparts. Not only did the study identify racial and ethnic disparities at the national level, but also at the individual NH level.
Mamede S, Zandbergen A, de Carvalho-Filho MA, et al. BMJ Qual Saf. 2024;33(9):563-572.
Anchoring bias occurs when a physician relies on their initial diagnostic impression despite subsequent information to the contrary. This study assessed the influence of disease knowledge on susceptibility to anchoring bias. In simulated case studies, physicians with higher disease knowledge were less likely than lower knowledge physicians to be biased by salient distracting features (e.g., patient presenting problem description with or without mention of family history of unrelated disease).
Rotenstein L, Wang H, West CP, et al. Jt Comm J Qual Patient Saf. 2024;50(6):458-462.
Team-based care is one approach to addressing the increasing burden of burnout among clinicians. Based on survey findings from 968 practicing physicians, higher perceptions of teamwork climate and safety climate were associated with lower odds of burnout. The researchers also found that physicians practicing in academic medical centers had lower odds of burnout compared to those working in private practice, after controlling for teamwork climate and safety climate.
Burus T, Lei F, Huang B, et al. JAMA Oncol. 2024;10(4):500-507.
Many people delayed care or were unable to get care during the first year of the COVID-19 pandemic. This study estimates the missed diagnoses of screenable cancers from March to December 2020. Diagnoses of included cancers were 6% lower than would be expected, even 10 months after the start of the pandemic. The greatest decrease was seen in prostate cancer, followed by breast and lung cancers, with an overall estimate of more than 134,000 missed cancer diagnoses.
Singh HK, Claeys KC, Advani SD, et al. Infect Control Hosp Epidemiol. 2024;45(4):405-411.
Healthcare-associated infections (HAIs) remain a common complication during inpatient care. This article summarizes diagnostic stewardship strategies to reduce the occurrence of HAIs and contrasts a patient-centered approach to diagnostic stewardship (focused on improving patient care) with a metric-centered approach (focused on reducing HAI rates through changes in diagnostic testing).
Holtsmark C, Larsen MH, Steindal SA, et al. J Clin Nurs. 2024;33(10):3831-3843.
As part of the rapid response team (RRT), critical care nurses (CCN) serve as team leaders to prevent patient deterioration. This review identified three themes regarding the ways critical care nurses experience being part of the RRT team: balancing between confidence and fear in clinical encounters, facilitating collaboration, and managing challenging power dynamics in decision-making.
Finn M, Walsh A, Rafter N, et al. BMJ Open Qual. 2024;13(2):e002506.
Along with improvements to patient safety, interventions to optimize safety culture can also improve staff outcomes. This review highlights the effects safety culture interventions have on hospital staff, what may explain these effects, and how staff experience these changes. Teamwork and collaboration, leadership support for safety, and just culture were the most reported themes.
Capper T, Ferguson B, Muurlink O. Women Birth. 2024;37(3):101593.
Staff reports are important in identifying and addressing problems. This review highlights the experiences of staff who raised concerns about patient safety threats in maternal and neonatal care. Structural power, perfectionism, and bravery, hope, and disappointment were identified as overall themes regarding the decision to speak up. Notably, the majority of included studies were from the United Kingdom, highlighting the need for other regions to conduct similar research.
No results.
Knees M, Raffel KE, Kissler M, et al. Rockville, MD: Agency for Healthcare Research and Quality; May 2024. Publication No. 24-0010-2-EF.
Cognition plays a crucial role in how clinicians perceive, interpret, and integrate information during the diagnostic process. This AHRQ issue brief summarizes key concepts of cognitive load theory (CLT), describes the relationship between CLT and diagnostic accuracy, and provides recommendations for future efforts to optimize cognition and decrease diagnostic errors.
Rockville, MD: Agency for Research and Quality; July 15, 2024. PA-24-261.
Health systems are increasingly developing, testing, and deploying artificial intelligence (AI) to support patient care. This funding opportunity focuses on assessing the impact, both positive and negative, of actual AI deployments in healthcare delivery systems and how that impact can be affected by implementation and use strategies.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute Care. 2024;29(9):1-4.
Pharmacogenomics (PGx) refers to the impact of genetic variation on an individual’s response to medications. This article describes how one children’s hospital is using PGx to reduce adverse drug reactions and outlines recommendations for implementing a PGx testing program.
This Month’s WebM&Ms
WebM&M Cases
Sharmilee Vuyyuru, DO, and Nandakishor Kapa, MD |
A 57-year-old man was rushed to the Emergency Department from a nursing facility, struggling to breathe. With a history of hypertension, diabetes, and heart failure, his vital signs were concerning, showing high blood pressure, rapid heart rate, and low oxygen levels. Examinations revealed fluid buildup in his lungs and legs, indicating severe heart and kidney problems. Despite attempts to remove excess fluid with medication, dialysis became necessary. However, a complication arose during catheter insertion, requiring emergency surgery to retrieve a misplaced guidewire.
WebM&M Cases
Spotlight Case
Andrew P.J. Olson, MD, FACP, FAAP |
Five weeks after gastric bypass surgery, a woman experienced persistent nausea and vomiting, leading to dehydration and multiple outpatient treatments. Despite visiting an outpatient clinic and emergency department (ED) for ongoing symptoms and significant weight loss, the nausea and vomiting persisted. Eventually, she was admitted to the ICU with pancreatitis and dehydration. Subsequently, she exhibited neurological symptoms including difficulty walking, tingling sensations, and cognitive impairment. She was discharged with orders for total parenteral nutrition (TPN). Three days after discharge, she was readmitted for worsening confusion and profound motor weakness, which progressed to respiratory failure requiring mechanical ventilation. Laboratory tests revealed an extremely low thiamine level, and the patient was diagnosed with advanced Wernicke-Korsakoff Syndrome, exacerbated by a lack of proper nutrition, and resulting in permanent brain damage, necessitating ongoing care. The commentary discusses how biases associated with medical conditions, such as obesity and its treatment, can lead to poorer outcomes, as well as strategies to continually re-evaluate diagnostic reasoning in light of ongoing, intensive management and management reasoning
WebM&M Cases
Spotlight Case
Elizabeth Gould, NP-C, CORLN, Krystal Craddock, BSRC, RRT, RRT-ACCS, RRT-NPS, AE-C, CCM, Tyler Le Tellier, RRT, Brooks T Kuhn, MD, MAS |
A 55-year-old man with a history of osteoarthritis and supraventricular tachycardia was admitted the hospital with severe COVID-19 and required endotracheal intubation and invasive mechanical ventilation. Following transfer to a long-term care hospital (LTCH) for continued weaning from mechanical ventilation, inadequate tracheostomy management protocols were evident, with no specific instructions provided. Subsequently, the patient experienced respiratory distress and cardiac arrest due to a blocked tracheostomy tube, highlighting critical deficiencies in care and communication. The commentary summarizes the risk factors for tracheostomy complications, the importance of tracheostomy tube maintenance and monitoring, and strategies to safeguard tracheostomy tube care during transitions of care.
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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