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May 29, 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
Brashear J, Mize R, Laposata M, et al. Diagnosis (Berl). 2024;11(2):132-135.
Diagnostic management teams (DMT), which are comprised of experts in specialized fields, review patient cases and produce reports with diagnostic interpretations and recommendations for future testing or treatments. This pre/post study evaluates the effectiveness of a coagulation DMT at one hospital. Cases reviewed by the DMT were twice as likely to have a diagnostic conclusion (i.e., ruled in or ruled out coagulopathy) than cases without DMT.
Evans C, Da’Costa A. Emerg Nurse. 2024;32(6):32(6):15-20.
Delayed handovers from emergency medical services (EMS) to the emergency department (ED) can significantly increase the risk of medical complications. This article describes a two-phase quality improvement project to decrease overall handover times as well the percentage of handovers occurring more than 60 minutes after arrival. Strategies included creation of a designated area for patients awaiting hospital admission, detailed written policies, and regular meetings between ED staff and ambulance services to improve working relationships and communication. This resulted in a decrease in the percentage of handovers more than 60 minutes after arrival from 9% to 0.2%, and an increase from 52% to 69% of handovers completed in 15 minutes or less.
Fentie AM, Huluka SA, Gebremariam GT, et al. Res Social Adm Pharm. 2024;20(5):487-497.
Oncology medications are high-risk due to complexity of patient care and patient polypharmacy. This review and meta-analysis highlights the impact of randomized control studies employing pharmacist-led interventions in oncology. Despite the heterogeneity of the included studies, pharmacist interventions can reduce medication errors in oncology. More research is required in low- and middle-income countries.
Evans C, Da’Costa A. Emerg Nurse. 2024;32(6):32(6):15-20.
Delayed handovers from emergency medical services (EMS) to the emergency department (ED) can significantly increase the risk of medical complications. This article describes a two-phase quality improvement project to decrease overall handover times as well the percentage of handovers occurring more than 60 minutes after arrival. Strategies included creation of a designated area for patients awaiting hospital admission, detailed written policies, and regular meetings between ED staff and ambulance services to improve working relationships and communication. This resulted in a decrease in the percentage of handovers more than 60 minutes after arrival from 9% to 0.2%, and an increase from 52% to 69% of handovers completed in 15 minutes or less.
Gomes KM, Handley J, Pruitt ZM, et al. J Patient Saf. 2024;20(5):345-351.
Evaluating the success of quality and safety interventions is essential to sustained improvements in patient safety. In this study, patient safety professionals from healthcare facilities and patient safety organizations (PSO) describe their processes for developing and evaluating patient safety interventions. Participants stated they consulted published tools/toolkits which they customized for their specific setting. None of the healthcare facility professionals used publicly available data which may be useful when developing their interventions
Zacherl KM, Sterrett EC, Hughes BL, et al. BMJ Qual Saf. 2024;33(6):396-405.
Pregnant patients with hypertensive disorders are at increased risk of further complications. In this quality improvement project, a multi-component intervention including remote blood pressure monitoring was found to increase the rate of completed postpartum blood pressure checks among individuals with hypertensive disorders of pregnancy.
Brashear J, Mize R, Laposata M, et al. Diagnosis (Berl). 2024;11(2):132-135.
Diagnostic management teams (DMT), which are comprised of experts in specialized fields, review patient cases and produce reports with diagnostic interpretations and recommendations for future testing or treatments. This pre/post study evaluates the effectiveness of a coagulation DMT at one hospital. Cases reviewed by the DMT were twice as likely to have a diagnostic conclusion (i.e., ruled in or ruled out coagulopathy) than cases without DMT.
Cosgrove SE, Ahn R, Dullabh P, et al. Jt Comm J Qual Patient Saf. 2024;50(6):435-441.
Antibiotic stewardship programs (ASP) are used in hospitals, long-term care, and ambulatory settings to reduce healthcare-associated infections and antibiotic-associated adverse events. This article focuses on the implementation of AHRQ’s Safety Program for Improving Antibiotic Use in acute care hospitals across the US in 2018. Participating hospitals reported the evidence-based content was helpful in raising awareness of the importance of antibiotic stewardship and creating local guidelines. Hospitals also reported challenges such engaging frontline staff and limited resources in smaller hospitals. Strategies to address challenges are discussed.
Harnisch M, Barnett ML, Coussens S, et al. JAMA Netw Open. 2024;7(4):e247604.
Antipsychotic medications are commonly prescribed to older adults with dementia to control behavioral symptoms despite research showing this practice to be harmful. In this randomized control study, primary care providers (PCPs) with high rates of quetiapine (an antipsychotic) prescribing were sent either a neutral letter (control) or a warning letter (intervention) from Centers for Medicare & Medicaid Services (CMS). The health outcomes of the PCPs' patients were analyzed at regular intervals. There were no statistically significant differences in health outcomes between the intervention and control groups. The largest decreases in prescribing were seen in lower-rated nursing homes without an increase in associated adverse events.
Studenmund C, Lyndon A, Stotts JR, et al. J Hosp Med. 2024;19(9):765-776.
Patients, family members, and caregivers have unique perspectives on safety practices in healthcare settings. This analysis of 68 narrative patient safety reports submitted by the family members of pediatric patients identified several elements important to patient safety and that are often difficult to assess from traditional incident reporting tools. These elements included the role of patient and family engagement, emotional safety, and system-centered care.
Commentary
McCarthy CP, Wasfy JH, Januzzi JL. JAMA. 2024;331(19):1623.
Misdiagnosis includes both missing a condition that is present and diagnosing a condition that is not present, or overdiagnosis. This article describes the factors that contribute to overdiagnosis of myocardial infarction in emergency departments and strategies to overcome them.
Connolly A, Kirwan M, Matthews A. Int J Qual Health Care. 2024;36(2):mzae037.
Administrative datasets offer an efficient method of identifying potential adverse events (AE) but only if they accurately represent a patient’s hospitalization. Retrospective chart reviews are a common way to validate administrative datasets, and this review identified 56 such studies. A variety of methods, sampling strategies, and accuracy rates were identified. A consensus approach to definitions and validation strategies is needed.
Sattar R, Lawton R, Janes G, et al. BMC Health Serv Res. 2024;24(1):603.
Healthcare workers may experience a variety of emotionally charged situations in their daily work. Based on 90 studies, this systematic review identified seven categories of emotional triggers in healthcare settings, including workplace toxicity, the repercussions of safety events, and lack of leadership support. The authors note a need for future research exploring how emotions influence patient safety processes and outcomes.
Teja B, Bosch NA, Diep C, et al. JAMA Intern Med. 2024;184(5):474-482.
The use of central venous catheters (CVC) can lead to different types of preventable complications resulting in serious patient harm. This meta-analysis estimated that approximately 3% of patients who have a CVC for three days experience one or more serious complication. Of all complications, placement failure and arterial puncture were the most common ones (20.4 and 16.2 events per 1,000 catheters, respectively).
Fentie AM, Huluka SA, Gebremariam GT, et al. Res Social Adm Pharm. 2024;20(5):487-497.
Oncology medications are high-risk due to complexity of patient care and patient polypharmacy. This review and meta-analysis highlights the impact of randomized control studies employing pharmacist-led interventions in oncology. Despite the heterogeneity of the included studies, pharmacist interventions can reduce medication errors in oncology. More research is required in low- and middle-income countries.
Ranard BL, Park S, Jia Y, et al. J Crit Care. 2024;82:154796.
Artificial intelligence (AI) is susceptible to the same sociodemographic biases as are humans, as, for example, when AI learns from biased data. This review details potential sources of bias across the AI lifecycle and proposes strategies to reduce bias.
No results.
Newspaper/Magazine Article
Aviv R. New Yorker. May 20, 2024.
Identifying criminal behavior in healthcare settings can be difficult. This article discusses challenges in the investigation of a British nurse serial murderer and implications for healthcare processes and systems.
Lucian Leape Institute. Boston: Institute for Healthcare Improvement; 2024.
The use of generative artificial intelligence (AI) in healthcare presents opportunities and challenges. This report summarizes an expert panel's review and discussion of generative AI in three use cases (documentation support, clinical decision support, and patient-facing chatbots); a detailed review of mitigation and monitoring strategies; and an appraisal of the implications of generative AI for the patient safety field.
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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