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August 28, 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
Ethington S, Volpe A, Guenter P, et al. Nutr Clin Prac. 2024;39(5):1251-1258.
Despite organizational guidelines, federal reports, and equipment redesign, tubing misconnections continue to occur. This review updates the 2011 article, Tubing misconnections: normalization of deviance, with a further 96 case reports of errors resulting from tubing misconnections. Harm was reported in 69% of cases and death was reported in 4% of cases. The authors urge all healthcare organizations to transition from universal connectors to syringes and tubing designed to be compatible only with themselves (for example, use of enteral tube with a unique connector that cannot be connected to an intravenous syringe).
Krenitsky NM, Perez-Urbano I, Goffman D. J Clin Med. 2024;13(14):4245.
Eliminating preventable maternal morbidity and mortality is a global public health challenge. Missed and delayed diagnosis is a key contributor to preventable maternal harm. This article outlines five research methods and a framework in which researchers can study rates of harm due to diagnostic error.
Noghrehchi P, Hefner JL, Walker DM. Health Care Manage Rev. 2024;49(4):281-290.
Previous research has shown that a positive safety culture can improve patient outcomes. This cross-sectional study examined the association between hospital patient safety culture and performance on Centers for Medicare & Medicaid Services (CMS) Hospital Value-Based Purchasing (HVBP) metrics. The researchers found that a positive patient safety culture was associated with better overall hospital performance scores and better scores on specific HVBP domains reflecting safety and patient engagement.
D'Angelo JD, Rivera M, Rasmussen TE, et al. Surgery. 2024;176(2):319-323.
When intraoperative errors occur, surgeons must cope with and recover from the error in both the short- and long-term. This article describes the implementation of the evidence-based STOPS framework (Stop, Talk to your team, Obtain help, Plan, Succeed) to improve resident surgeon coping skills and impact on burnout. Three months after introducing the STOPS framework, women residents reported higher coping self-efficacy, whereas there were no statistically significant differences for men residents. Both genders reported lower levels of burnout.
Mumford V, Raban MZ, Li L, et al. Br J Clin Pharmacol. 2024;90(7):1615-1626.
Measuring the incidence and severity of potential or actual harm is an ongoing challenge in patient safety. In this study at one pediatric hospital, researchers evaluated a new systematic approach using multidisciplinary review to assess actual harm from inpatient medication errors. Among 566 cases identified via medical record review and direct observation of medication administration, the multidisciplinary panel identified actual harm in 89 cases, with three-quarters of actual harm occurring in medication administration cases.
Jin Q, Chen F, Zhou Y, et al. NPJ Dig Med. 2024;7(1):190.
Numerous studies have evaluated Generative Pre-trained Transformer’s (GPT) accuracy in response to text-only questions. This study appraises GPT-4 with Vision (GPT-4V), which analyzes images and text together. GPT-4V performs similarly to physicians regarding multiple choice accuracy, but demonstrates flawed rationale even when it selected the correct response.
Martin G, Pralat R, Waring J, et al. J Health Serv Res Policy. 2024;Epub Aug 2.
Dedicated patient safety specialists support organizational safety systems and safety culture. In 2019, the English National Health Service (NHS) asked each NHS organization to identify at least one senior-level patient safety specialist. In this study, current patient safety specialists participated in interviews and/or responded to a survey regarding implementation and enactment of the role. Respondents reported experiencing varied levels of organizational support and highlighted tensions between a focus on strategic goals and maintaining an understanding of "work as done.”
Grailey K, Brazier A, Franklin BD, et al. BMJ Qual Saf. 2024;30(10):682-690.
When used correctly, barcode medication administration (BCMA) technology promotes safer medication administration. This study aimed to increase nurses' use of BCMA in five hospital wards through a feedback intervention. BCMA use increased during the first six weeks of the intervention then plateaued during the final 12 weeks. The average scan rate at the end of the 18-week intervention significantly increased from 15% to 38%; however, this was lower than the researchers’ ultimate target of 95%.
Peerally MF, Carr S, Waring J, et al. J Patient Saf. 2024;20(6):440-447.
Patient safety incident investigations offer unique opportunities to encourage continuous learning and system improvements. Researchers in this study analyzed 126 action plans generated from serious event investigations at one hospital in the United Kingdom to assess how well the proposed patient safety actions generated from incident investigations aligned with contributing factors identified in the investigations. The analysis found that 15% of contributory factors were not addressed by the action plans and that three-quarters of proposed risk controls outlined in the plans were weak (focusing on individual rather than systemic issues).
Guzikevits M, Gordon-Hecker T, Rekhtman D, et al. Proc Natl Acad Sci U S A. 2024;121(33):e2401331121.
Bias against women is, unfortunately, common in healthcare, which can result in undertreatment. This study analyzed emergency department discharge notes for more than 21,000 patients which showed that physicians and nurses are more likely to doubt women's pain reports and prescribe less pain-relieving medication compared to men with the same self-reported pain score.
Millan PD, Kleiman AM, Friedman JF, et al. J Clin Anesth. 2024;97:111549.
Hindsight bias refers to the tendency to judge events leading to an adverse event as errors because the bad outcome is already known, thus describing the outcome as preventable. This study presented anesthesia providers with two case scenarios—one which stated the diagnosis at the beginning of the scenario (hindsight) and one which did not (foresight). Providers assigned higher probability to the diagnosis in the hindsight scenarios than in the foresight scenarios. When providers review adverse events, they should consider the impact of hindsight bias in interpreting clinical outcomes.
Noghrehchi P, Hefner JL, Walker DM. Health Care Manage Rev. 2024;49(4):281-290.
Previous research has shown that a positive safety culture can improve patient outcomes. This cross-sectional study examined the association between hospital patient safety culture and performance on Centers for Medicare & Medicaid Services (CMS) Hospital Value-Based Purchasing (HVBP) metrics. The researchers found that a positive patient safety culture was associated with better overall hospital performance scores and better scores on specific HVBP domains reflecting safety and patient engagement.
Krenitsky NM, Perez-Urbano I, Goffman D. J Clin Med. 2024;13(14):4245.
Eliminating preventable maternal morbidity and mortality is a global public health challenge. Missed and delayed diagnosis is a key contributor to preventable maternal harm. This article outlines five research methods and a framework in which researchers can study rates of harm due to diagnostic error.
Macleod H, Greenfield D. Int J Qual Health Care. 2024;36(3):mzae074.
In 2024, the World Health Organization (WHO) shared a comprehensive report examining the current state of patient safety work worldwide. This commentary builds on the WHO findings and introduces intersecting factors stalling improvement while highlighting a range of multifocal, yet collectively supportive, strategies to advance patient safety effort success and sustainability.
Wiig S, Calderwood CJ, O’Hara J. Healthcare (Basel). 2024;12(15):1532.
Normalization of deviance occurs when poor practices are common throughout an organization despite their associated safety hazards. This article suggests that patient and family experiences in healthcare can serve as an early warning to signal potential safety risks and improve safety culture.
Ethington S, Volpe A, Guenter P, et al. Nutr Clin Prac. 2024;39(5):1251-1258.
Despite organizational guidelines, federal reports, and equipment redesign, tubing misconnections continue to occur. This review updates the 2011 article, Tubing misconnections: normalization of deviance, with a further 96 case reports of errors resulting from tubing misconnections. Harm was reported in 69% of cases and death was reported in 4% of cases. The authors urge all healthcare organizations to transition from universal connectors to syringes and tubing designed to be compatible only with themselves (for example, use of enteral tube with a unique connector that cannot be connected to an intravenous syringe).
No results.
Newspaper/Magazine Article
Crouch M. AARP. August 06, 2024;
Medication self-management can become increasingly complicated as patients age and take more medications. This article highlights key behaviors that support safe medication use. Cautions regarding pill splitting and taking missed doses appropriately are included.
Bradford A, Ehsan S, Shahid U, et al. Rockville, MD: Agency for Healthcare Research and Quality; July 2024. AHRQ Publication No. 24-0010-3-EF
The reliability and timeliness of electronic test result delivery can support safe, high-quality care while introducing the potential for patient and family emotional harm. This issue brief identifies current evidence and best practices to inform patient-centered implementation of test result communication through patient portals under the 21st Century Cures Act.
Kawamoto K, Greysen SR, Heaney-Huls K, et al. Rockville, MD: Agency for Healthcare Research and Quality; June 2024. AHRQ Publication No. 24-0069-1
Artificial intelligence (AI) is envisioned to play a role in disseminating information that improves medical decision making. This report introduces existing methods for using AI to scale patient-centered clinical decision support (PC CDS), summarizes prevailing challenges, and pinpoints promising strategies to ensure patient safety and privacy.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute Care. August 08, 2024;29(16).
Wrong patient errors, availability of expired human milk products, component shortages and recalls degrade the safety and effectiveness of enteral nutrition (EN) therapy. This article shares recommendations to embed barcode scanning into the EN formula selection, compounding, and administration process.
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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