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September 4, 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
Campione Russo A, Tilly J‐L, Kaufman L, et al. J Hosp Med. 2024;Epub Aug 20.
In 2021, the Leapfrog Group established the Recognizing Excellence in Diagnosis initiative to prevent patient harm due to diagnostic errors. They subsequently issued the report "Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals," detailing 29 practices to improve diagnostic safety. This article summarizes the extent to which 95 Leapfrog hospitals have implemented the recommended practices. The most frequently implemented practices were ensuring access to medical interpreters, continuous access to radiologists, ensuring staff and patients can report diagnostic errors and concerns, and having a formal process to identify and notify patients when diagnostic errors occur. The practice with the most room for improvement is CEO commitment to diagnostic excellence.
MacKinnon KM, Seshadri S, Mailman JF, et al. Crit Care Explor. 2024;6(8):e1140.
Although evidence of their effectiveness is somewhat mixed, checklists are ubiquitous in hospital care. This meta-analysis found some improved patient outcomes (e.g., reduced in-hospital and intensive care unit mortality) in facilities using a rounding checklist in the ICU. Providers had a generally positive perception of rounding checklists, particularly around team collaboration. Further randomized studies are needed to increase certainty of evidence.
Commentary
Zaslow J, Fortier J, Garber G. BMJ Qual Saf. 2024;33(9):613-616.
Never events are serious, but preventable, adverse events that result in serious patient harm or death. This article compares how organizations define never events with respect to preventability, presence and severity of harm, and public accountability. The authors discuss how varying definitions present challenges in conceptualizing and standardizing never event measurement and reporting.
Schlesinger M, Dhingra I, Fain BA, et al. BMJ Open Qual. 2024;13(3):e002848.
Adverse events and patient safety events can lead to long-term psychological harm for patients and caregivers. This survey of 253 patients who experienced an adverse event within the past 5 years found that just over one-third of patients felt initially abandoned or betrayed by their healthcare provider after the incident; 20% of respondents reported experiencing persistent abandonment lasting as long as six years after the initial incident. These findings highlight the importance of open disclosure and communication after patient safety events to maintain positive patient-provider relationships.
Schols LA, Maranus ME, Rood PPM, et al. J Patient Saf. 2024;20(6):420-425.
Misdiagnosis in the emergency department (ED) is estimated to affect over 7 million patients each year and can lead to increased morbidity and mortality. This retrospective study conducted at one academic medical center evaluated identified diagnostic errors by comparing discordance between ED diagnosis and discharge diagnosis after hospital admission. The researchers identified a difference in diagnosis between the ED physician and the discharge diagnosis in 1 in 6 patients; these cases were associated with longer length of stay and additional diagnostic discrepancies.
Campione Russo A, Tilly J‐L, Kaufman L, et al. J Hosp Med. 2024;Epub Aug 20.
In 2021, the Leapfrog Group established the Recognizing Excellence in Diagnosis initiative to prevent patient harm due to diagnostic errors. They subsequently issued the report "Recognizing Excellence in Diagnosis: Recommended Practices for Hospitals," detailing 29 practices to improve diagnostic safety. This article summarizes the extent to which 95 Leapfrog hospitals have implemented the recommended practices. The most frequently implemented practices were ensuring access to medical interpreters, continuous access to radiologists, ensuring staff and patients can report diagnostic errors and concerns, and having a formal process to identify and notify patients when diagnostic errors occur. The practice with the most room for improvement is CEO commitment to diagnostic excellence.
Craig SR, Smith HL, Shaeffer PJ. Ochsner J. 2024;24(2):118-123.
Adverse event and near miss reports are central to identifying and reconciling patient safety concerns, but their voluntary nature results in low reporting rates particularly for resident physicians. This article details a quality and patient safety improvement project aimed at increasing reporting rates for resident physicians at a community hospital. Following implementation of the multifaceted improvement project, reporting rates increased, which resulted in several safety improvements.
Jacobsen HK, Ballangrud R, Birkeli GH. Nurs Crit Care. 2024;Epub Jun 26.
A diverse array of methods exists to report and learn from patient safety incidents. This study describes post-anesthesia care unit (PACU) nurses' experience with the Green Cross method, a proactive method to report and learn from patient safety incidents occurring in the prior 24 hours. Nurses reported more openness and transparency after implementation of the Green Cross method; however, they also reported that subsequent improvements were insufficient.
Kachalia A, Vanhaecht K. NEJM Catalyst. 2024;5(9).
Safety and quality improvement initiatives face many implementation challenges. This report details how members of the NEJM Catalyst Insights Council rate their organizations on quality and safety initiatives. Key takeaways include the challenges associated with an ever-increasing amount of data, limited resources such as staff shortages, and lack of leadership involvement.
LeStrange N, Walton AM, Watson JL, et al. Clin J Oncol Nurs. 2024;28(4):397-405.
In many clinical areas such as primary care, advanced practice providers (APP), including nurse practitioners and physician assistants, are licensed to practice independent of physician supervision. This study evaluated the rate of chemotherapy prescribing adverse events and near misses submitted to the institutional reporting system for both oncology physicians and APPs. The odds of a reported event were higher for physicians than APPs. However, given the voluntary and subjective nature of event reporting, the study was unable to determine if actual patient harm occurred in either group.
Joskowicz L, Di Veroli B, Lederman R, et al. Eur J Radiol. 2024;176:111530.
Cancer is among the "Big Three" types of diagnosis most vulnerable to misdiagnosis. This study aimed to reduce false positives and false negatives by reading three or more consecutive radiological scans of patients with cancer. Scans were read by human readers and artificial intelligence; reading three consecutive scans improved accuracy when compared to reading only two consecutive scans.
Recsky C, Stowe M, Rush KL, et al. Stud Health Technol Inform. 2024;315:452-457.
Health information technology (HIT) can further safety in healthcare but can also introduce threats to patient safety. This article describes the development of a structured process to enhance the ability of clinical informaticists to incorporate patient safety into health information processes and address HIT-related safety issues.
Commentary
Zaslow J, Fortier J, Garber G. BMJ Qual Saf. 2024;33(9):613-616.
Never events are serious, but preventable, adverse events that result in serious patient harm or death. This article compares how organizations define never events with respect to preventability, presence and severity of harm, and public accountability. The authors discuss how varying definitions present challenges in conceptualizing and standardizing never event measurement and reporting.
MacKinnon KM, Seshadri S, Mailman JF, et al. Crit Care Explor. 2024;6(8):e1140.
Although evidence of their effectiveness is somewhat mixed, checklists are ubiquitous in hospital care. This meta-analysis found some improved patient outcomes (e.g., reduced in-hospital and intensive care unit mortality) in facilities using a rounding checklist in the ICU. Providers had a generally positive perception of rounding checklists, particularly around team collaboration. Further randomized studies are needed to increase certainty of evidence.
Alabdaly A, Hinchcliff R, Debono D, et al. BMC Health Serv Res. 2024;24(1):906.
Patient satisfaction/experience and staff perceptions of safety culture are commonly utilized as indicators of patient safety. In this review, positive patient satisfaction/experience was associated with positive staff (but not management) perceptions of safety culture. Teamwork and communication were the most influential factors on patient experience and staff patient safety culture. Future studies on safety culture should include qualitative and quantitative reports of patient experience.
No results.
Rockville, MD: Agency for Healthcare Research and Quality; May 2024. AHRQ report no. 24-0010-6-EF
Clinical laboratory expertise and routine clinical decision-making can be improved through diagnostic stewardship. This issue brief reviews existing approaches toward diagnostic stewardship implementation. It discusses how these practices can support diagnostic excellence and avenues toward measuring their impact.
Newspaper/Magazine Article
Raphael K. New York Times. August 26, 2024;
Lack of shared understanding and crisp definition of medical actions can have lasting impacts on patients, families, and clinicians. This story describes the harm that families and patients face when do-not-resuscitate (DNR) orders are inaccurately followed or unknown to care teams.
This Month’s WebM&Ms
WebM&M Cases
Christian Bohringer, MBBS, Adam Guemidjian, and Garth Utter, MD, MSc |
An 8-year-old boy undergoing a neck mass aspiration experienced a sudden drop in oxygen saturation and heart rate, requiring CPR and intubation, due to being administered nitrous oxide instead of oxygen following a maintenance error by an inadequately trained employee. The patient was transferred to the intensive care unit (ICU) on a ventilator but remained unresponsive and died. The commentary discusses several approaches to improving patient safety during anesthesia administration in the surgical suite, such as use of oxygen analyzers and considering hypoxic gas mixture as the cause for sudden deterioration.
WebM&M Cases
Spotlight Case
David K. Barnes, MD, FACEP and Garth Utter, MD, MSc, FACS |
A man presented at the emergency department (ED) after a motorcycle crash. He had superficial lacerations on his left elbow, where wood chips were noted on exam and x-ray but were not fully removed before discharge. He was discharged with antibiotic prescriptions, but returned three days later with worsening symptoms, including pain, swelling, and pus, leading to additional foreign material being removed and further antibiotic treatment, but without repeat x-rays. Ultimately, he developed osteomyelitis, requiring multiple surgeries and a long hospital stay due to the retained foreign bodies. The commentary highlights the importance of evaluating patient risk of wound infection and poor wound healing, the role of imaging modalities to help identify foreign material in wounds, and diligent follow-up to prevent complications.
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.
This Month’s Perspectives
Interview
<p><span>Carole Stockmeier, Sarah Mossburg, Lee Merton</span></p><p> </p> |
Carole Stockmeier, MHA, BS, is the Senior Vice President of Safety and Reliability Solutions at Press Ganey, with over 20 years of experience in safety science and high reliability organizations. We spoke to her about zero harm and patient safety.
Interview
<p>Eric Thomas, Sarah Mossburg, Merton Lee</p> |
Eric Thomas, MD, MPH, is the Director of the University of Texas Houston Memorial Hermann Center for Healthcare Quality and Safety and is Associate Dean for Healthcare Quality. We spoke to him about zero harm and patient safety.
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