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July 17, 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
Meer A, Rahm P, Schwendinger M, et al. J Med Internet Res. 2024;26:e58157.
Patients presenting to the emergency department (ED) are triaged to prioritize care based on level of illness. In this study, 2,543 patients presenting to an ED in Switzerland were asked to self-triage using an electronic symptom-checker. (Patients were triaged and treated based on standard-of-care nurse triage.) Recommendations were given regarding time to treat (e.g., emergency) and point-of-care (e.g., self-care) and subsequently evaluated by three panels of experts. Fifty of the 2,543 patients were judged as undertriaged, but none were judged as potentially hazardous.
Scott J, Sykes K, Waring J, et al. J Adv Nurs. 2024;Epub Jun 19.
Incident reporting systems are commonly used to detect threats to patient safety. This systematic review of 106 studies examined the characteristics of incident reporting processes in residential care facilities and nursing homes in high-income countries. The authors summarize how incidents are detected; common contributing, mitigating, and ameliorating factors; as well as actions and interventions to reduce the risk of patient safety incidents.
White AT, Vaughn VM, Petty LA, et al. Clin Infect Dis. 2024;78(6):1403-1411.
Misdiagnosis of infections can lead to overuse of antibiotics and threaten patient safety. This article describes the development of two National Quality Forum (NQF)-endorsed measures of inappropriate diagnosis of urinary tract infection (UTI) and community-acquired pneumonia (CAP). Both measures demonstrated strong validity and reliability through testing with patient focus groups and case review. Implementation evaluation across more than 40 Michigan hospitals demonstrated significant decreases in inappropriate diagnoses of UTI and CAP, indicating broad usability of these measures to support improved outcomes.
Meer A, Rahm P, Schwendinger M, et al. J Med Internet Res. 2024;26:e58157.
Patients presenting to the emergency department (ED) are triaged to prioritize care based on level of illness. In this study, 2,543 patients presenting to an ED in Switzerland were asked to self-triage using an electronic symptom-checker. (Patients were triaged and treated based on standard-of-care nurse triage.) Recommendations were given regarding time to treat (e.g., emergency) and point-of-care (e.g., self-care) and subsequently evaluated by three panels of experts. Fifty of the 2,543 patients were judged as undertriaged, but none were judged as potentially hazardous.
Hess A, Flicek T, Watral AT, et al. Jt Comm J Qual Patient Saf. 2024;50(9):673-677.
"Second victim syndrome" occurs when an adverse event or error has a negative emotional impact on involved staff, including shame, depression, and loss of confidence. This article describes a debriefing tool for nurses who have just experienced an adverse event. The tool, BONE Break (Buoy/Break, Open-Up, Needs, Exit/Evaluate), is intended to be used as soon as possible after the event to provide peer support to the impacted nurse.
White AT, Vaughn VM, Petty LA, et al. Clin Infect Dis. 2024;78(6):1403-1411.
Misdiagnosis of infections can lead to overuse of antibiotics and threaten patient safety. This article describes the development of two National Quality Forum (NQF)-endorsed measures of inappropriate diagnosis of urinary tract infection (UTI) and community-acquired pneumonia (CAP). Both measures demonstrated strong validity and reliability through testing with patient focus groups and case review. Implementation evaluation across more than 40 Michigan hospitals demonstrated significant decreases in inappropriate diagnoses of UTI and CAP, indicating broad usability of these measures to support improved outcomes.
Gyberg A, Brezicka T, Wijk H, et al. J Clin Nurs. 2024;33(11):4421-4433.
Patient complaints, either during or after hospitalization, can be used as a measure of patient safety. In this study, recently hospitalized patients described the various ways they tried to improve their safety during care and sought to prevent future harm. The overarching theme identified by the researchers was the importance of navigating the path of least suffering. The the ability of patients to act independently reduced their vulnerability.
Zheng L, Pon T, Bajorek SA, et al. J Am Coll Clin Pharm. 2024;7(8):787-794.
Pharmacists play an important role in medication reconciliation and decreasing medication discrepancies during admission and discharge. This evaluation of 31 patients participating in pharmacist-led discharge medication reconciliation found that 68% of patients had at least one medication error at discharge. Three-quarters of these errors were deemed serious and commonly involved duplication errors or medication access barriers.
Longwell JB, Hirsch I, Binder F, et al. JAMA Netw Open. 2024;7(6):e2417641.
A common way to test the accuracy and limitations of large language models (LLM) is by prompting it to answer standardized questions. This study used medical oncology examination questions from the American Society of Clinical Oncology (ASCO), the European Society for Medical Oncology (ESMO), and original questions constructed by the study team to test the accuracy of several open source and proprietary LLMs. Accuracy varied by LLM, and many incorrect answers, if acted upon in practice, had the potential for patient harm.
Cooper WO, Hickson GB, Dmochowski RR, et al. JAMA Netw Open. 2024;7(6):e2415331.
Unprofessional behavior creates an environment prone to complications, poor staff communication, and loss of patient trust. In participating hospitals, staff can submit safety reports about coworkers demonstrating unprofessional behavior to the Coworker Concern Observation Reporting System (CORS). This study breaks down CORS reports by physician specialty (nonsurgeon nonproceduralists, emergency medicine physicians, nonsurgeon proceduralists, and surgeons). Less than 10% of all staff had 1 or more reports. Surgeons had the highest percentage of physicians with at least one CORS report (13.8%) and nonsurgeon nonproceduralists had the least (5.6%). A subanalysis compared pediatric and non-pediatric specialists. Pediatric nonsurgeon nonproceduralists had fewer reports compared to nonpediatric nonsurgeon nonproceduralists. There were no differences between the other three groups.
Ayre MJ, Lewis PJ, Phipps DL, et al. Health Expect. 2024;27(3):e14095.
People with mental illness frequently receive treatment from their primary care providers. In this study, people with mental illness, their caregivers, and healthcare providers detailed their perspectives on mental health medication safety within primary care. Communication, timely access, and continuity of care were identified as important factors for ensuring medication safety. Patients and caregivers also highlighted the importance of patient-centered guidelines and resources for providers.
Kalinowski J. N Engl J Med. 2024;390(23):e61.
Personal stories of poor care can catalyze the need for improvement. This editorial shares the experience of a Black scientist who both witnessed and received indifferent care as a woman of color. She suggests efforts to hire ethnically diverse clinicians and health care leaders, accompanied by improved implicit bias training as avenues toward reducing health care harm associated with bias.
Lenk MA, LaMantia S, Oehler J, et al. Hosp Pediatr. 2024;14(8):e372-e377.
For quality improvement projects to be successfully, sustained, interventions require a high level of reliability. This article lays out the three levels of reliability (LOR). Level 1: intent, vigilance, and hard work; Level 2: human factors and reliability science; Level 3: design for high reliability. Case examples from children's hospitals are used to illustrate the levels.
Gomes KM, Apathy N, Krevat SA, et al. J Patient Saf. 2024;20(5):358-359.
Telehealth emerged as a primary strategy for care delivery during the COVID pandemic despite concerns about its reliability. This commentary outlines a framework outlining how infrastructure, clinical application and patient safety concepts can align to ensure safe telehealth.
Carmack HJ, Lazenby BS, Wilson KJ, et al. Am J Clin Pathol. 2024;162(4):349-355.
Lost, mislabeled, and mishandled pathology specimens can lead to delayed diagnosis and uncertainty for patients. This review analyzed the evidence on specimen errors during the pre-analytical stage. Most articles were US-based and focused on mislabeling errors. Interventions included standardized processes and checklists, and the authors recommend that future articles include implementation strategies to support other facilities in replicating their successes.
Ohlsen JT, Søfteland E, Akselsen PE, et al. BMJ Qual Saf. 2024;Epub Jun 6.
Successful implementation of effective patient safety strategies remains an organizational challenge. In this systematic review including 159 studies, the authors explored factors influencing successful implementation of three common patient safety practices: medication reconciliation, antibiotic stewardship programs, and rapid response systems. The researchers identified several common factors supporting effective implementation, including clinical competence, engagement, and organizational support. The authors suggest additional research examining continuous adaptations to address changing contexts and support sustained improvements.
Scott J, Sykes K, Waring J, et al. J Adv Nurs. 2024;Epub Jun 19.
Incident reporting systems are commonly used to detect threats to patient safety. This systematic review of 106 studies examined the characteristics of incident reporting processes in residential care facilities and nursing homes in high-income countries. The authors summarize how incidents are detected; common contributing, mitigating, and ameliorating factors; as well as actions and interventions to reduce the risk of patient safety incidents.
No results.
Rockville, MD: Agency for Healthcare Research and Quality; June 2024. AHRQ Pub. No. 24-0017-2-EF.
Care coordination is defined as the process of organizing patient care activities and sharing information among all individuals concerned with a patient’s care to achieve safe and effective care. This publication summarizes 47 projects that examine the impact of care coordination to enhance patient safety.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute Care. 2024;29(13):1-4.
Patient and family concerns can provide insights that should be welcomed to improve safety. This article summarizes a case where problems were not responded to, and harm occurred. The article shares recommendations drawn from a national action plan to enable effective response to voiced concerns. The areas of focus include organizational culture, leadership, patient/family engagement, workforce safety, and the learning system.
Multi-use Website
University of California, San Francisco.
Diagnostic excellence is an emergent field of study that aligns with diagnostic error reduction efforts. This center will provide learning opportunities, broad community engagement, and innovations support to stimulate collective improvement in diagnosis through attainment of progress toward excellence.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Scott Zakaluzny, MD, FACS |
A 67-year-old man with severe low back pain was admitted to the hospital for anterior lumbar interbody fusion (ALIF) with bone autograft from the iliac crest. The surgical team had difficulty controlling bleeding and the patient left the operating room (OR) with the bone graft donor site open and oozing blood. In the postanesthesia care unit (PACU), the nurse called the attending physician three times to report hypotension and ongoing bleeding. Each time, the surgeon ordered hetastarch for volume expansion. Over the next 14 hours, the patient’s blood pressure remained at or below 90/60 with continued complaints of back and pelvic pain. The next morning, the patient was unresponsive and in severe hypovolemic shock. Electrocardiography confirmed a non-ST segment elevation myocardial infarction (NSTEMI). The patient was transferred to an intensive care unit and resuscitative efforts were initiated, but the patient expired from multiorgan failure resulting from hypovolemic shock. The commentary discusses appropriate management of ongoing intraoperative and postoperative bleeding and how a culture of safety can enable care team members to voice concerns about patient safety.
WebM&M Cases
Christian Bohringer, MB BS and Gustavo Chavez, MD |
A 36-year-old woman with class 2 obesity underwent a difficult laparoscopic hysterectomy, performed in the lithotomy position with a steep head down (Trendelenburg) position. Intermittent pneumatic compression devices were placed on both calves to prevent venous thrombosis (DVT), but on awakening from general anesthesia, the patient complained of severe pain in the right leg. The gynecologist made a presumptive diagnosis of DVT and put her on subcutaneous dalteparin at therapeutic dosing and acetaminophen and oral morphine for pain relief. The patient continued to complain of severe pain and paresthesias in her right calf and doppler ultrasound scan was negative for DVT. The next day the orthopedic on-call team was consulted and diagnosed compartment syndrome of the right leg. The patient required fasciectomy of the right leg and excision of necrotic muscle tissue, with a prolonged hospital stay. The commentary discusses how patient positioning during surgery can increase the risk for surgical complications, the role of interdisciplinary teamwork to achieve optimal positioning, and the importance of early identification of compartment syndrome to prevent permanent injury.
WebM&M Cases
Paul MacDowell, PharmD, BCPS and Eloh McGee, PharmD |
A 19-month-old boy was being transferred to a tertiary medical center from another emergency department after undergoing comprehensive resuscitation efforts due to cardiopulmonary arrest. The transport clinician intended to administer rocuronium (a neuromuscular blocking agent) to treat ventilator desynchrony, but instead unintentionally administered flumazenil (a benzodiazepine antagonist). The clinician promptly corrected the error by administering the appropriate dose of rocuronium. The commentary highlights the importance of “double checks” during medication administration and how both technologic approaches and human factors engineering principles can support safe medication administration practices.
This Month’s Perspectives
Interview
Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD |
Amy Helwig, MD, MS, FAAFP, is the Chief Quality Officer at Commonwealth Care Alliance. We spoke to her about the health plan’s role in monitoring and improving patient safety.
Perspectives on Safety
Amy Helwig, MD, MS, FAAFP, Zoe Sousane, BS, Sarah Mossburg, RN, PhD |
This piece explores the health plan’s role in improving patient safety, including how health plans are monitoring patient safety and health plan-level initiatives to improve patient safety.
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