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October 9, 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
Jones BE, Chapman AB, Ying J, et al. Ann Intern Med. 2024;177(9):1179-1189.
An accurate diagnosis of pneumonia ensures that appropriate treatment can be administered in a timely manner. In this large retrospective study, researchers compared hospital admission and discharge diagnosis of community-acquired pneumonia. More than half of patients had a discordant diagnosis at discharge. EHR notes described more uncertainty for patients with discordance. This study highlights the importance of understanding diagnostic uncertainty in pneumonia-related care.
Padula WV, Pronovost PJ. J Patient Saf. 2024;20(7):512-515.
Despite considerable health system efforts and governmental financial penalties, hospital-acquired conditions (HAC) continue to be a source of patient harm and organizational cost. Instead of the current model of financial penalties and non-payment for low-performing hospitals, the authors recommend rewarding high-performing hospitals and development of centers of excellence. They suggest the investment in HAC prevention would be less than costs associated with treatment, in addition to keeping patients safe from harm.
Norman G, Pelaccia T, Wyer P, et al. J Eval Clin Pract. 2024;30(5):788-796.
Diagnostic reasoning is frequently discussed in terms of System 1 (thinking fast) and System 2 (thinking slow). The authors of this review present evidence against the claim that diagnostic error stems solely from System 1 thinking. They conclude that errors originate from both System 1 and System 2 thinking. Errors typically occur due to lack of access to the appropriate knowledge, and neither system is essential to the process of diagnostic reasoning.
Sweeting P, Finlayson M, Hartz D. Jt Comm J Qual Patient Saf. 2024;50(10):711-718.
Suicide is considered a never event in healthcare settings. Using data from 2009 to 2018, researchers used the Human Factors Analysis and Classification System (HFACS) for Healthcare to identify modifiable risk factors contributing to inpatient suicide in Australia. Common contributing factors include decision errors (e.g., failure to address patient deterioration), problems with the physical environment, and operational mismanagement (e.g., insufficient oversight of junior staff).
Padula WV, Pronovost PJ. J Patient Saf. 2024;20(7):512-515.
Despite considerable health system efforts and governmental financial penalties, hospital-acquired conditions (HAC) continue to be a source of patient harm and organizational cost. Instead of the current model of financial penalties and non-payment for low-performing hospitals, the authors recommend rewarding high-performing hospitals and development of centers of excellence. They suggest the investment in HAC prevention would be less than costs associated with treatment, in addition to keeping patients safe from harm.
Jones BE, Chapman AB, Ying J, et al. Ann Intern Med. 2024;177(9):1179-1189.
An accurate diagnosis of pneumonia ensures that appropriate treatment can be administered in a timely manner. In this large retrospective study, researchers compared hospital admission and discharge diagnosis of community-acquired pneumonia. More than half of patients had a discordant diagnosis at discharge. EHR notes described more uncertainty for patients with discordance. This study highlights the importance of understanding diagnostic uncertainty in pneumonia-related care.
Wegwarth O, Hoffmann TC, Goldacre B, et al. BMJ Qual Saf. 2024;33(10):634-641.
Clinical decision making is a complex process that can be influenced by a variety of factors. This cross-sectional study included 304 general practice physicians in the United Kingdom and explored the association between risk literacy (a physician’s ability to understand numerical statistical information, such as relative vs absolute risk, related to medical interventions) and prescribing of potentially hazardous drugs. The analysis found that practitioners with higher risk literacy prescribed significantly fewer potentially hazardous drugs (e.g., opioids, gabapentin, benzodiazepines) compared with physicians with low risk literacy; antibiotic prescribing was similar between the two groups.
Al-Bazzaz H, Janicijevic M, Strand F. Eur Radiol. 2024;34(8):5415-5424.
Artificial intelligence (AI) can support mammography reading in several ways, including as a second reader and via decision support. In this study, 758 mammograms were read by human radiologists with no AI support and read again 6 weeks later, this time with the AI-predicted diagnosis of positive or negative for cancer. AI support resulted in a decrease in sensitivity and increase in specificity compared to human-only reading. The prevalence of cancer in the sample was higher than in the general population (1:1 cancer to healthy ratio), which also affected the readers' accuracy.
Taylor MA, Yonash RA. Patient Safety. 2024;6(1):1-11.
Previous research has found that inaccurate consent documents and procedural schedules can lead to patient harm, such as wrong-site surgery. Using the Pennsylvania Patient Safety Reporting System (PA-PSRS) database, researchers identified 1,166 consent and/or scheduling errors over a 4-year period. Of these errors, 56% were schedule errors and 34% were consent errors (10% involved both). Errors predominantly occurred at hospitals (86%, vs 14% at ambulatory surgery centers). Risk factors for consent and schedule errors included low health literacy and nonstandardized forms and/or workflows.
Averill P, Bowness B, Henderson C, et al. BMC Health Serv Res. 2024;24(1):1053.
Community-based mental health care receives less research attention than other care types and locations. In this study, people who have used community-based mental health care, carers, and providers shared their perspectives on what safety means in that setting. Four themes were uncovered: (1) systemic challenges, such as access to care; (2) managing risks to patients or those around them; (3) how clinicians can cause harm or proactively prevent it; and (4) safe care is a work in progress.
Norman G, Pelaccia T, Wyer P, et al. J Eval Clin Pract. 2024;30(5):788-796.
Diagnostic reasoning is frequently discussed in terms of System 1 (thinking fast) and System 2 (thinking slow). The authors of this review present evidence against the claim that diagnostic error stems solely from System 1 thinking. They conclude that errors originate from both System 1 and System 2 thinking. Errors typically occur due to lack of access to the appropriate knowledge, and neither system is essential to the process of diagnostic reasoning.
Wiig S, Lyng HB, Guise V, et al. J Patient Saf. 2024;20(7):e109-e114.
Resilient healthcare organizations can effectively adapt to challenges and changes while delivering safe, high quality patient care. The Resilience in Healthcare (RiH) Research Program is a large-scale, multi-country study of resilience and adaptive capacity across different healthcare settings (i.e., hospitals, nursing homes, home care). In this paper, the authors share lessons learned and highlight several recommendations for policymakers to improve resilience in health care, including the role of patients and caregivers, creating a culture of collaborative learning, and the importance of relational leadership.
Hartmann CW, Clark V, Nash P, et al. J Am Med Dir Assoc. 2024;25(9):105014.
This commentary discusses the application of organizational resilience concepts in the nursing home environment as a strategy toward adapting to change in real time to enhance care quality. The authors highlight a program that supports the implementation of resiliency that supports staff and their ability to deliver safe care.
Cole R, Roderick G, Cheema O, et al. J Adv Nurs. 2024;Epub Sep 25.
Hospitalized patients are routinely monitored by multiple electronic devices that alert clinical staff when readings exceed a specified range. Given the large number of devices, one patient may generate dozens of alerts per day, which contributes to alert fatigue. This review highlights alert fatigue in pediatric and neonatal hospital wards along with successful interventions to reduce alerts. Most alarms were associated with physiological monitoring. Only half of the studies included an intervention, the majority of which focused on changes to alarm parameters.
Rosen MA, Stewart CM, Kharrazi H, et al. J Patient Safety Risk Manag. 2024;29(4):178-188.
The number of telehealth visits increased exponentially at the start of the COVID-19 pandemic, necessitating research into their safety and effectiveness. This rapid review identified 23 studies on the safety of telehealth visits in a diverse array of settings and specialties. Most studies reported rates of adverse events for telehealth visits that were similar to in-person visits. None of the studies included interventions to improve patient safety, but the authors note that interventions implemented during the COVID-19 pandemic may not yet have been published.
Aunger JA, Abrams R, Westbrook JI, et al. Health Soc Care Deliv Res. 2024;12(25):1-195.
Unprofessional behavior negatively affects patient safety and staff well-being. This narrative review characterized how, why, and under what circumstances unprofessional behavior occurs in acute care and what interventions have been implemented to reduce it. Factors contributing to unprofessional behavior include workplace disempowerment, organizational uncertainty, confusion and stress, lack of social cohesion, and enablement of harmful cultures that tolerate unprofessional behaviors. Staff members from ethnic minority groups were at increased risk of being targets of unprofessional behavior.
United States Meeting/Conference
Agency for Healthcare Research and Quality. October 30, 2024, 1:00-2:00 PM (eastern).
Handoffs are susceptible to relational factors affected by organizational culture. This session will highlight the use of Surveys on Patient Safety Culture ™ (SOPS®) Hospital Survey to inform handoff improvement efforts. Presenters will describe strategies for administering the SOPS Survey at their organization and explain how their survey results and SOPS resources are currently used to improve handoffs in medical-surgical units.
Newspaper/Magazine Article
Neklason A. The Hill. September 23, 2024;
Appropriate treatment of pain is a complicated process vulnerable to racial, ethnic, and gender biases. This two-part story discusses system and biological factors that affect pain treatment for women and research on the existence of the disparities.
Book/Report
de Bienassis K, Slawomirski L, Kelly D, et al. Paris, France: OECD Publishing; 2023.
Ineffective diagnostic processes are common, wasteful, and harmful. This analysis examines system design, work environment factors, and individual skills that degrade diagnosis and outlines the economic ramifications of these embedded problems across health care.
Epstein HM, Haskell H, Hemmelgarn C, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2024. AHRQ Publication No. 24-0010-8-EF
While patient involvement in health care is often discussed, it is not engrained in how care transpires. This issue brief examines how system characteristics can impede true communication and partnership between patients, their families and clinicians, and their organizations. The brief advocates for structures that engage individuals, recognize patient expertise, and build trust to fully bring patients into the diagnostic process to ensure its effectiveness and safety. This brief is from a series of reports on the topic of diagnostic excellence.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Garth Utter, MD |
A 38-year-old man sustained multiple injuries in a motorcycle crash, including head trauma, chest injuries, and spinal fractures. Attempts to intubate him to manage his respiratory distress were unsuccessful and he underwent emergency cricothyroidotomy. Despite initial neurological evaluations indicating normal extremity movements, he developed progressive paralysis of his lower extremities over the hospital course. A delayed MRI revealed a significant epidural hematoma compressing his spinal cord from C3 to C7, prompting emergency surgery. Despite decompression, he suffered permanent paralysis. The commentary highlights the cognitive pitfalls associated with managing and processing large volumes of clinical information and the importance of effective communication and active engagement among all clinical team members.
WebM&M Cases
Spotlight Case
Ryan Martin, MD, FCNS and Kiarash Shahlaie, MD, PhD, FAANS, FCNS |
A man in his mid-50s presented to the hospital with a persistent headache after a sledding injury. A head CT scan was read as normal and he was diagnosed with a minor head injury and discharged without any specific treatment. Three weeks later, he presented with ongoing symptoms including worsening cognition and increased headache and was diagnosed with post-concussive syndrome and discharged without specific treatment. He was later diagnosed with a large frontal subdural hematoma requiring urgent surgery. The commentary discusses risk factors for delayed acute subdural hematoma and the importance of repeat brain imaging in patients with risk factors and persistent symptoms.
WebM&M Cases
Victoria Jackson, DNP, RN, PHN, FNP-C, PA-C and Anna Satake, PhD, MSN, GCNS, RN |
These cases involve two elderly patients presenting to the emergency department (ED) who suffered falls during their care, despite recognition of risk factors including previous ground-level falls. The commentary summarizes risk factors for fall injuries among high-risk populations (such as older adults), appropriate use of fall assessment and prevention strategies, and strategies to improve communication between healthcare team members to reduce the risk of patient falls.
This Month’s Perspectives
Interview
Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd |
Elizabeth Salisbury-Afshar, MD, MPH, is an Associate Professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health and Medical Director of the Compass Program, a low-barrier walk-in clinic for substance-related health concerns.
Perspective
Elizabeth Salisbury-Afshar, MD, MPH, Bryan Gale, MA, Sarah Mossburg, Phd |
This piece provides an overview of the philosophy of harm reduction, as well as specific strategies for how it can improve safety for people who use substances.
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