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August 21, 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
Johansen RLR, Tulloch S. J Patient Saf. 2024;20(5):e78-e84.
Quality improvement (QI) and patient safety initiatives can be challenging to implement and sustain. The article proposes incorporating behavioral insights (BI) into QI to enhance and reinforce behaviors to support positive change. The authors describe using BI in a QI program to increase actions and behaviors more aligned with safe use of intravenous antibiotics at one hospital in Denmark.
Marsteller JA, Rosen MA, Wyskiel R, et al. Jt Comm J Qual Patient Saf. 2024;50(10):737-744.
Effective communication and coordination among care teams is essential to the delivery of high quality, safe health care. This article introduces the Multi-Team Shared Expectations Tool (MT-SET), which is used to improvement team communication, engage teams in eliciting needs and establishing shared expectations among teams and individuals. A pilot evaluation of the MT-SET in perioperative and inpatient care units at Johns Hopkins University School of Medicine found that the MT-SET tool fostered better cross-unit teamwork and coordination, but issues such as care delays and inconsistent communication persist.
Snowdon A, Hussein A, Danforth M, et al. J Med Internet Res. 2024;26:e56316.
Digital maturity in healthcare refers to how well hospitals use digital systems to improve patient care processes, enhance patient safety, and provide quality health care. This study used the Electronic Medical Record Assessment Model (EMRAM) to examine the relationship between digital maturity and Leapfrog’s quality and safety scores. Among 1,026 hospitals, researchers found that higher digital maturity was associated with improved odds of achieving a higher Leapfrog hospital safety grade, indicating advanced patient safety outcomes.
White AA, King AM, D’Addario AE, et al. JAMA Netw Open. 2024;7(8):e2425923.
Open disclosure of errors is increasingly encouraged in health care and emphasized in health profession training. This randomized trial evaluated the effectiveness of video-based communication assessment (VCA) feedback in resident error disclosure skill training. The researchers found that internal medicine and family medicine residents who received individual feedback on simulated error disclosure performance scored significantly higher on subsequent error disclosure assessments, as compared to residents who did not receive feedback.
Snowdon A, Hussein A, Danforth M, et al. J Med Internet Res. 2024;26:e56316.
Digital maturity in healthcare refers to how well hospitals use digital systems to improve patient care processes, enhance patient safety, and provide quality health care. This study used the Electronic Medical Record Assessment Model (EMRAM) to examine the relationship between digital maturity and Leapfrog’s quality and safety scores. Among 1,026 hospitals, researchers found that higher digital maturity was associated with improved odds of achieving a higher Leapfrog hospital safety grade, indicating advanced patient safety outcomes.
Carlqvist C, Ekstedt M, Lehnbom EC. BMC Geriatr. 2024;24(1):520.
Polypharmacy in older adults, particularly those with dementia, can increase the risk of patient safety events. This qualitative study evaluated whether integrating pharmacists into care teams at special housing for older adults in Sweden improved medication safety. Findings from semi-structured interviews and content analysis revealed that pharmacists are perceived to be important members of the care team, but communication barriers within teams hinders medication safety.
Leonard C, Gilmartin HM, Starr LM, et al. J Healthc Risk Manag. 2024;44(1):17-23.
Like many health care organizations, the Veterans Health Administration (VHA) is working towards becoming a high-reliability organization (HRO). In this qualitative study, researchers interviewed 14 current and past leaders involved in HRO transformation at the Harry S. Truman Memorial Veterans' Hospital. Leaders identified three key strategies for achieving high reliability: (1) consistent communication from leadership and modeling of HRO principles, (2) empowering frontline staff to make changes and fail, and (3) hiring and training team members in alignment with organizational culture and HRO values.
Gao C, Lage C, Scullin MK. J Clin Sleep Med. 2024;20(6):933-940.
Sleep deprivation or changes to circadian rhythm (such as those introduced by daylight savings time, or DST) can hinder the delivery of safe health care. In this analysis of 288,432 malpractice claims between January 1990 and September 2018, researchers found that the spring transition to DST was not associated with higher severity patient safety incidents, but that events occurring during the 7-8 months of DST were more severe compared to the 2-4 months of standard time.
Bauer ME, Perez SL, Main EK, et al. Eur J Obstet Gynecol Reprod Biol. 2024;299:136-142.
Delayed diagnosis and management of sepsis can lead to significant patient harm. This qualitative study explored patient perspectives about near-miss events and deaths due to maternal sepsis. The focus groups and interviews identified four key issues important for future quality improvement efforts: insufficient awareness of sepsis warning signs, atypical symptoms, dismissal of concerns leading to delayed diagnosis, and difficulty accessing follow-up care.
Gahn K, Hwang M, Cho Y, et al. Stud Health Technol Inform. 2024;315:398-403.
Patients with higher medication complexity, such as patients with cancer, are particularly vulnerable to medication safety events (MSEs). This qualitative study with patients with breast, prostate, lung, and colorectal cancer identified several barriers to the use of technology for MSE self-reporting, such as limited access to technology and low confidence in using technology.
Hampton S, Murray J, Lawton R, et al. BMJ Qual Saf. 2024;Epub Aug 6.
Transitions of care between the hospital and home can jeopardize patient safety for a myriad of reasons, such as communication gaps and poor care coordination. This article evaluates the implementation of hybrid “Your Care Needs You” (YCNY) intervention in the UK’s National Health Services (NHS), which aims to improve the safety of care transitions from hospital to home by supporting patients in (1) managing health and well-being, (2) medication management, (3) completing activities of daily living, and (4) anticipating needs and escalating care. Qualitative evaluations and observations found that YCNY goals resonated with patients, but that implementation was often hampered by time constraints and understaffing.
Johansen RLR, Tulloch S. J Patient Saf. 2024;20(5):e78-e84.
Quality improvement (QI) and patient safety initiatives can be challenging to implement and sustain. The article proposes incorporating behavioral insights (BI) into QI to enhance and reinforce behaviors to support positive change. The authors describe using BI in a QI program to increase actions and behaviors more aligned with safe use of intravenous antibiotics at one hospital in Denmark.
Halm MA. Am J Crit Care. 2024;33(4):305-310.
High-reliability organizations are built on elements that reduce hierarchy, improve communication, and recognize expertise in team members during times of crisis. This summary of the literature explores evidence supporting the use of huddles to enhance transparency and information sharing. It provides a sample structure for HRO huddles at the unit level.
Wang X, Rihari‐Thomas J, Bail K, et al. J Adv Nurs. 2024;Epub Aug 2.
Missed nursing care can lead to lower quality of care and threaten patient safety. This systematic review including 24 articles evaluated methods for measuring missed nursing care in long-term aged care (LTAC) settings. The authors concluded that existing tools are inconsistently applied and lack strong methodologic verification; additional research to develop standardized, validated tools is needed.
Abo-Zahhad M, El-Malek AHA, Sayed MS, et al. BioData Min. 2024;17(1):17.
Retained surgical items (RSIs) remain a persistent patient safety problem. This review examined the use of machine learning (ML) and deep learning (DL) tools to support RSI prevention and detection and how these applications can be integrated with existing safety practices in perioperative care.
No results.
Washington, DC: The Veterans Affairs Inspector General; 2024. Report No. 23-02179-188
Health care leaders have a critical role in establishing and supporting a robust culture of safety. This report analyzed the environment of care at one Veterans’ Affairs hospital that perpetuated poor psychological safety, thereby reducing improvement opportunities. The examination concluded that the responsibility for the situation sat squarely with organizational leadership, who dismissed staff concerns, failed to examine factors contributing to problems, and fostered an unsafe deference to hierarchy. Recommendations for improvement focus on improving use of human resources strategies to generate needed change.
Rockville, MD: Agency for Healthcare Research and Quality; June 2024.
The recognition of diagnosis as a team activity is energizing new diagnostic process initiatives. Building on the established TeamSTEPPS® principles, this new TeamSTEPPS course includes seven training modules, team and knowledge assessment tools, and implementation guidance to develop or enhance communication across the care team to improve the accuracy and timeliness of diagnosis. Training opportunities for August, September, and October 2024 are now available for registration.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Justin L. Devera, MD, David K. Barnes, MD, FACEP, and William R. Lewis, MD |
A 54-year-old man with a history of tobacco use presented to the emergency department (ED) with acute chest pain. He was initially stable upon arrival, though with signs of fluid overload and electrolyte abnormalities including hyponatremia and hyperkalemia. Despite treatment including heparin, amiodarone, and metoprolol for atrial fibrillation, and interventions for hyperkalemia, the patient deteriorated rapidly into cardiac arrest characterized by Torsades de pointes, which was mistaken for ventricular fibrillation. Despite resuscitative efforts, he did not achieve return of spontaneous circulation and autopsy revealed sudden cardiac arrest without myocardial infarction as the cause of death. The commentary highlights how the misinterpretation of a common laboratory complication can lead to incorrect treatment and patient harm.
WebM&M Cases
Commentary by Brittany Newton, PharmD and Roslyn Seitz, MPH, MSN |
An adolescent with type 1 diabetes presented to the emergency department (ED) with dizziness, fatigue, and a “high” reading on her home blood glucose monitor. She was diagnosed with diabetic ketoacidosis (DKA) likely due to insulin pump malfunction. Despite initial treatment, her condition did not improve as expected. Later, it was discovered that an incorrect weight was used to calculate her insulin drip rate, based on a guessed weight provided by the patient upon admission. Once her actual weight was used to adjust treatment, her DKA resolved rapidly within 12 hours. The commentary discusses how human factors engineering and electronic health record (EHR) functionalities can optimize weight measurement during patient encounters and the role of clinical pharmacists in the ED to improve medication safety.
WebM&M Cases
Commentary by Robert M. Szabo, MD, MPH, FAOA |
A woman underwent surgery for carpal tunnel syndrome without complications and was discharged with instructions to avoid soaking her hand in water (to reduce infection risk) and return for suture removal in 10 days. Despite reporting symptoms such as warmth, redness, and pain in her wrist shortly after surgery, her concerns were not adequately addressed by the surgeon's office. The patient returned for suture removal and visit notes stated that the wound was not infected or swollen. However, the patient continued to report pain, swelling, redness and oozing at the incision site after suture removal. Two weeks later, she presented to the emergency department (ED) and diagnosed with a severe infection, leading to multiple hospitalizations and permanent impairment of her right hand. The commentary discusses the importance of preoperative discussions about post-operative care, including sterile practices, and the use of protocol-based management strategies for medical office personnel to ensure that patient interactions and communication are appropriately documented and acted upon
This Month’s Perspectives
Perspectives on Safety
Chalapathy Venkatesan, MD, MS, CPPS, Kathy Helak, MSN, BSN, RN, FACHE, CPPS, Zoe Sousane, BS, Cindy Manaoat Van, MHSA, CPPS |
Dr. Chalapathy Venkatesan is the Chief Quality and Safety Officer, and Kathy Helak is the Assistant Vice President for Patient Safety at Inova Health System. We spoke to them about Safety-II principles and their application at Inova.
Perspective
Chalapathy Venkatesan, MD, MS, CPPS, Kathy Helak, MSN, BSN, RN, FACHE, CPPS, Zoe Sousane, BS, Cindy Manaoat Van, MHSA, CPPS |
This piece provides an overview of Safety-II principles and discusses ways healthcare systems are integrating Safety-II principles into safety programs and care delivery.
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