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November 6, 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
Lam A, Plombon S, Garber A, et al. Appl Clin Inform. 2024;15(4):733-742.
The failure of a provider to communicate the diagnosis to the patient is a diagnostic error. This communication includes not only telling the patient what their diagnosis is but also ensuring they understand it. In this study, hospitalized patients were asked if "the healthcare team told you the main reason you're in the hospital (your diagnosis) in a way you understand" and their level of confidence in the diagnosis. Just under half of patients reported the same diagnosis as indicated in the electronic health record (EHR), ie, diagnostic concordance. Patients admitted with nonspecific symptoms ("R-codes") and those reporting less confidence in their diagnosis experienced lower diagnostic concordance. Non-English speakers were not included in the study, which the authors recognize as a limitation as this population is particularly vulnerable to suboptimal communication and misdiagnosis.
Manuel R, Barber A, Kern J, et al. Ped Qual Saf. 2024;9(5):e767.
Interprofessional communication and teamwork is critical to patient safety. First-year medical and nursing residents participated in team engagement sessions focused on collaboration and safety behaviors through socialization, team communication, and engagement skills. Sessions consisted of a pre-recorded scenario of a safety event resulting in a patient's death followed by a facilitated debrief. Escalation of care, SBAR (situation, background, assessment, recommendation), and “ask a question, make a request, voice a concern” were identified as the top 3 safety/communication techniques that could have changed the outcome of the simulated scenario. Approximately two-thirds of participants perceived lack of confidence and fear of giving the wrong information as barriers to safety/communication techniques.
Ouanes K, Farhah N. J Med Syst. 2024;48(1):74.
Artificial intelligence-based clinical decision support systems (AI-CDSS) hold promise for improving patient outcomes. This review identified 26 articles on the effectiveness of AI-CDSS on patient outcomes. The content analysis revealed 4 themes: early detection and disease diagnosis, enhanced decision-making, medication errors, and clinicians' perspectives. Only 3 of the interventions, which were within the theme of early detection and disease diagnosis, were categorized as highly effective. Patient privacy, data security, and health equity were mentioned as continuing concerns.
Bartles R, Reese S, Gumbar A. Am J Infect Control. 2024;Epub Sep 25.
Infection preventionists play a key role in the prevention of healthcare-associated infections (HAI). This article describes the creation and validation of a calculator that uses risk and complexity factors to generate individualized infection prevention and control (IPC) staffing ratios. Based on data submitted by 390 US hospitals, including size and case mix index, the calculator estimated nearly 80% of respondents had lower than expected IPC staffing. Hospitals with below-expected staffing levels were more likely to have higher standardized infection ratios.
Davalos RA, Aden J, Pluta N, et al. J Surg Educ. 2024;81(11):1533-1537.
Poor usability results in clinicians spending considerable time working with electronic health records (EHR). Following a change in EHR vendors, residents in 1 orthopedics department were no longer able to automate a pre-populated inpatient list from the EHR; instead, they were required to manually transfer patient information from the EHR to another program, such as Word, prior to rounding and several times throughout the day. Residents were surveyed about the impact of this change on their education, wellness, and patient safety. Interns reported spending an average of 83 minutes per day using the automated list compared to 196 minutes per day with the manual list. Residents in all years reported this change negatively impacted their sleep and education and posed a risk to patient safety.
Manuel R, Barber A, Kern J, et al. Ped Qual Saf. 2024;9(5):e767.
Interprofessional communication and teamwork is critical to patient safety. First-year medical and nursing residents participated in team engagement sessions focused on collaboration and safety behaviors through socialization, team communication, and engagement skills. Sessions consisted of a pre-recorded scenario of a safety event resulting in a patient's death followed by a facilitated debrief. Escalation of care, SBAR (situation, background, assessment, recommendation), and “ask a question, make a request, voice a concern” were identified as the top 3 safety/communication techniques that could have changed the outcome of the simulated scenario. Approximately two-thirds of participants perceived lack of confidence and fear of giving the wrong information as barriers to safety/communication techniques.
Selman K, Roberts E, Niznik J, et al. J Am Geriatr Soc. 2024;72(Supp 3):s60-s67.
Inappropriate medications can increase the risk of falls among older adults. This observational study of older adults presenting to the emergency department (ED) after a fall evaluated the impact of medication reconciliation that targets high-risk medications to reduce future falls. Among 577 participants, almost 54% were taking a high-risk medication and received medication recommendations from a pharmacist. At 12-month follow-up, researchers did not observe a statistically significant difference in repeat fall-related visits overall or a difference in repeat fall-related visits between patients who modified their medications compared to those who did not.
Crouch K, Adamson L, Beldham‐Collins R, et al. J Med Radiat Sci. 2024;Epub Sep 15.
An incident learning system (ILS) can highlight system weaknesses and promote organizational learning to prevent future harm. This study aimed to assess staff reporting patterns and perspectives on safety culture after implementing a new ILS in a radiation oncology department. The percentage of respondents who reported feeling comfortable or very comfortable reporting increased from 49% to 75% after implementation. Post-implementation, 92% of staff felt the department practiced a no-blame culture, and nearly half thought the department showed an ability to learn. The biggest barrier to reporting in both periods was the amount of time it took to submit a report.
Lam A, Plombon S, Garber A, et al. Appl Clin Inform. 2024;15(4):733-742.
The failure of a provider to communicate the diagnosis to the patient is a diagnostic error. This communication includes not only telling the patient what their diagnosis is but also ensuring they understand it. In this study, hospitalized patients were asked if "the healthcare team told you the main reason you're in the hospital (your diagnosis) in a way you understand" and their level of confidence in the diagnosis. Just under half of patients reported the same diagnosis as indicated in the electronic health record (EHR), ie, diagnostic concordance. Patients admitted with nonspecific symptoms ("R-codes") and those reporting less confidence in their diagnosis experienced lower diagnostic concordance. Non-English speakers were not included in the study, which the authors recognize as a limitation as this population is particularly vulnerable to suboptimal communication and misdiagnosis.
Stephens WA, Anderson MJ, Levy BE, et al. J Am Coll Surg. 2024;239(4):387-393.
Standardized handoffs during perioperative care can improve patient safety. This article describes the development and implementation of an operating room handoff report called SHRIMPS, which highlights critical handoff elements for surgical technicians (eg, S stands for surgeon aware and sharps/sponges and other countable items). Researchers piloted the use of this handoff report in 15 surgical cases and found that it improved communication regarding nearly all critical elements.
Collings R, Potter C, Gebski V, et al. Am J Obstet Gynecol. 2024;Epub Aug 5.
Surgical complications can result in guilt, shame, anxiety, or depression—sometimes referred to as "second victim syndrome" (SVS)—for the health professionals involved. The study aimed to estimate the prevalence of SVS among OBGYN surgeons, its physical, mental, and emotional impact, and coping strategies. OBGYNs responding to the survey reported surgical complications were most stressful when they resulted in poor patient outcomes, had severe consequences for the patient, and when the complication occurred because of surgeon error. Younger and female surgeons were more likely to report mental health symptoms than older and male surgeons.
Page B, Irving D, Amalberti R, et al. BMJ Qual Saf. 2023;33(11):738-747.
Production pressures in health care can impact the delivery of patient care and threaten patient safety. In this scoping review, the authors developed a taxonomy of pressures and strategies for adapting to these pressures in health care settings. Among 17 included studies, pressures generally stemmed from lack of available resources. Strategies for adapting to these pressures included efficient management of workloads and resource flexing.
Wills VE. Ergonomics. 2024;Epub Aug 9.
Surgical never events have the potential for serious patient harm. This prospective study conducted between April 2021 and September 2022 used two approaches (the SEIPS framework and the CARe QI handbook) to explore how work-as-done and system resilience prevent never events in trauma and orthopedic surgery in the UK. Participating healthcare staff identified systems-level approaches to improve safety. Researchers observed a significant increase in mean time between the incidence of never events (from 46 to 224 days).
Singh H, Sittig DF, Classen DC. JAMA Intern Med. 2024;Epub Oct 28.
The infusion of innovation into the healthcare system requires a sociotechnical approach to minimize opportunities for unintended consequences and ensure that effective care results from the change. This commentary shares 5 contexts for exploring safe artificial intelligence (AI) implementation challenges: interoperability, safety measurement, adverse event prediction, large clinical database analysis, and generative AI development.
Arthur KJ, Fuller J, Dossett HA, et al. Am J Health Syst Pharm. 2024;Epub Sep 4.
Medication kits allow medications that are frequently administered together to be stored and dispensed together to improve patient safety. This article provides recommendations for creating, storing, and maintaining standardized medication kits. A WebM&M highlights errors that can happen when medication kits are not standardized and are poorly maintained.
Ouanes K, Farhah N. J Med Syst. 2024;48(1):74.
Artificial intelligence-based clinical decision support systems (AI-CDSS) hold promise for improving patient outcomes. This review identified 26 articles on the effectiveness of AI-CDSS on patient outcomes. The content analysis revealed 4 themes: early detection and disease diagnosis, enhanced decision-making, medication errors, and clinicians' perspectives. Only 3 of the interventions, which were within the theme of early detection and disease diagnosis, were categorized as highly effective. Patient privacy, data security, and health equity were mentioned as continuing concerns.
No results.
Institute for Safe Medication Practices; October 2024.
Like other medication processes, vaccine administration is vulnerable to errors. This report examined 1,987 reports submitted to the ISMP vaccine errors reporting initiative over a 2-year period. The data highlight various clinical settings where the errors occurred, the types of errors, and show that a majority of the submitted errors reached the patient.
Press Release/Announcement
Agency for Healthcare Research and Quality. Fed Register. October 31, 2024;
Artificial intelligence is of primary interest across the field of medicine, but there are concerns about its safety. The notice announces a public virtual meeting designed to collect input from patient safety organizations and others in the field on the design of a federal program on the safety of artificial intelligence in health care. The session will be held November 15th from 12:30 to 4:00 p.m. ET. Registration information is included in the materials.
Miller MA, Lin L, Calfee DP, et al. Rockville, MD: Agency for Healthcare Research and Quality; October 2024. HCUP Statistical Brief #314.
Healthcare-associated infections (HAI) are a persistent threat to patient safety. This report analyzes data from the Healthcare Cost and Utilization Project to compare local data from 38 states. A distinct set of large hospitals consistently had higher rates of HAIs compared with similar hospitals in 2019 and 2021. Of the HAIs reviewed, non-COVID associated rates of ventilator-associated pneumonia not present on admission increased by over 80%, surpassing rates of other infections.
Dorset, UK: Health Services Safety Investigations Body; September 2024.
Recommendations for improvement are only valuable if they are systemically designed and realized in practice. This report explores reasons why progress stalls given robust improvement suggestions submitted to address patient safety. Success can be hampered by various issues, including lack of initiative coordination and transparency, prioritization of actions, discussion of patient impact, and cost evaluation. Collective information and monitoring tools to track suggested actions and progress could enhance implementation of improvement ideas.
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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