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January 8, 2025 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
Gursel E, Madadi M, Coble JB, et al. Reliability Eng System Saf. 2025;256:110682.
Artificial intelligence (AI) and machine learning (ML) are being used and tested in numerous ways. This review highlights how they are being used to detect and mitigate human error in safety-critical industries, the limitations and challenges of AI/ML, and insights from the recent literature. Examples from health care include using AI to detect diagnostic errors and combining AI with clinician expertise, with the ultimate decision to follow AI’s suggestion resting with the clinician.
Patel SM, Fuller S, Michael MM, et al. Anesth Analg. 2024;Epub Nov 26.
Mnemonics are a commonly used memory aid to ensure standardized, structured handoffs between providers. This review summarizes mnemonics used in perioperative handoffs. Situation, Background, Assessment, Recommendation (SBAR) and SBAR variations were the most common, followed by I-PASS (Illness severity, Patient summary, Actions list, Situation awareness, Synthesis), and I-PASS variants. Most studies reported only on process outcomes; only four measured patient outcomes.
Schmidt M, Schauwinhold MT, Loeffler LAK, et al. Ann Med. 2024;56(1):2408458.
Learning from errors is a fundamental component of health professions education. This randomized trial examined the difference between two error-framing strategies—Error Management (EM) and Error Avoidance (EA)— on cardiopulmonary resuscitation (CPR) performance among first-year health professions students. The EA perspective aims to avoid errors as much as possible, even during the learning process. In contrast, the EM perspective fosters a positive approach to errors and considers them part of the learning process. Results found that EM led to equivalent or slightly better performance than EA and control arms. The authors conclude that EM is a promising approach for medical education given its potential long-term benefits for patient safety and non-detrimental effect on short-term performance.
Garcia BH, Omma KK, Småbrekke L, et al. Ther Adv Drug Saf. 2024;15:20420986241299683.
Potentially inappropriate medications (PIM) and potential prescribing omissions (PPO) in older adults are associated with adverse events, increased hospital readmissions, and lower health-related quality of life. This study aimed to estimate the prevalence of PIM and PPO at hospital admission and discharge and to explore the impact of clinical pharmacist involvement. Patients in the intervention group (with pharmacist involvement) had lower rates of PIM at discharge compared to the group receiving usual care (no pharmacist involvement). There was no difference in PPO between groups. Patients admitted from nursing homes and other institutional settings were at increased risk of PIM at discharge.
Kuitunen S, Saksa M, Holmström A-R. Drugs Real World Outcomes. 2024;Epub Dec 11.
Understanding how and when medication errors occur is necessary to implement medication management safety strategies. This study determined that most self-reported high-alert medication errors in a children’s hospital were associated with administration and prescribing. One-quarter of incidents included two to four errors, and wrong dose or omission were the most common. Systemic defenses are required to reduce wrong dose, omission, and documentation errors.
Dinis-Teixeira JP, Nunes AB, Leite A, et al. PLoS ONE. 2024;19(10):e0311896.
Standardized measures allow for comparison between facilities. This article describes the development of a “Core Measures Set” that should be measured and reported in surgical care in the context of the "Improving quality and patient SAFEty in surgical care through STandardisation and harmonization of perioperative care in Europe" (SAFEST) project. Subject-matter experts and patients agreed on 85 measures. The three most important measures were: (1) availability of equipment to administer oxygen to all patients requiring procedural sedation by anesthesiologists, (2) presence of an up-to-date preoperative medication list in the clinical records, and (3) documented internal policy defining resuscitation is available to all care providers.
Van Poel E, Vanden Bussche P, Collins C, et al. Fam Pract. 2024;Epub Oct 30.
The COVID-19 pandemic presented numerous challenges to the safe delivery of health care. This cross-sectional study, including general practitioner practices in 37 European countries and Israel, found that structural issues (e.g., building or infrastructure limitations) and inconsistent implementation of safety protocols challenged patient safety during the COVID-19 pandemic.
Schmidt M, Schauwinhold MT, Loeffler LAK, et al. Ann Med. 2024;56(1):2408458.
Learning from errors is a fundamental component of health professions education. This randomized trial examined the difference between two error-framing strategies—Error Management (EM) and Error Avoidance (EA)— on cardiopulmonary resuscitation (CPR) performance among first-year health professions students. The EA perspective aims to avoid errors as much as possible, even during the learning process. In contrast, the EM perspective fosters a positive approach to errors and considers them part of the learning process. Results found that EM led to equivalent or slightly better performance than EA and control arms. The authors conclude that EM is a promising approach for medical education given its potential long-term benefits for patient safety and non-detrimental effect on short-term performance.
Upadhyay S, Chien L-C. J Patient Saf. 2024;20(8):542-548.
Hospital-physician integration provides physicians with opportunities to be engaged in organizational management and to influence organizational culture. Using data (including from the Hospital Survey on Patient Safety Culture™ [SOPS®]), this cross-sectional study explores the impact of hospital-physician integration on patient safety culture. Study findings suggest a significant positive relationship between higher levels of physician integration and perceptions of hospital management support for patient safety. Findings did not identify a significant correlation with communication openness or organizational learning. These findings highlight the need for future research on integration and patient safety as more physicians take on management roles.
Crompton A, Waring J, Macrae C, et al. J Health Serv Res Policy. 2024;Epub Nov 5.
The UK's Healthcare Safety Investigation Branch (HSIB)—rebranded as the Health Services Safety Investigation Body in October 2023—conducted independent investigations of patient safety incidents in the NHS and recommended systemwide improvements. This article describes the challenges associated with the implementation and development of the HSIB. Challenges included independence and fit within the wider system, the selection and scope of investigations, the methodology and investigation approach, and the skill and competencies of investigators.
Abel GA, Agniel D, Elliott MN. BMJ Qual Saf. 2024;34(1):53-61.
Governments and organizations frequently identify high- and low-performing healthcare organizations for public reporting, quality improvement, or payment. This article highlights the pitfalls of the most common statistical methods used to identify high and low performers and asserts that reliable data is required to minimize incorrect categorization.
Militello LG, Diiulio J, Wilson DL, et al. J Am Med Inform Assoc. 2024;Epub Nov 21.
The potential for bias in artificial intelligence (AI) training data is a well-known problem, but the potential for bias resulting from a poorly designed user interface (UI) is less studied. The authors use their experience developing a machine learning-based clinical decision support tool to highlight three considerations in designing UIs for AI applications: (1) bias is not just about the algorithm, (2) it is possible to identify bias and interpretation errors before an application is released, and (3) risk communication strategies can influence bias in unexpected ways.
DelDot M, Lau E, Rayner N, et al. Health Expect. 2024;27(6):e70092.
As end users of medication safety interventions, consumers (e.g., patients, caregivers, families) are key research team members. This review summarizes studies on interventions developed and designed with consumers to improve medication safety in primary care. Consumers were involved in the planning and engagement stages of most studies, but less frequently involved in other stages, such as making decisions on the final product or outcomes. The authors recommend increased reporting of how consumers were involved, the types of consumers, and the impact and quality of their involvement.
Patel SM, Fuller S, Michael MM, et al. Anesth Analg. 2024;Epub Nov 26.
Mnemonics are a commonly used memory aid to ensure standardized, structured handoffs between providers. This review summarizes mnemonics used in perioperative handoffs. Situation, Background, Assessment, Recommendation (SBAR) and SBAR variations were the most common, followed by I-PASS (Illness severity, Patient summary, Actions list, Situation awareness, Synthesis), and I-PASS variants. Most studies reported only on process outcomes; only four measured patient outcomes.
Tchijevitch O, Hansen SM-B, Hallas J, et al. Jt Comm J Qual Patient Saf. 2025;51(1):46-73.
Learning from medication errors (MEs) is essential to enhance patient safety. This scoping review of 59 articles published between 2017 and 2023 identified a wide variety of methods for analyzing medication errors, including advanced techniques, such as text mining and artificial intelligence (AI). The authors highlight the growing use of newer methods, such as disproportionality analysis, and the need for further research into their effectiveness and applicability in analyzing ME data.
Gursel E, Madadi M, Coble JB, et al. Reliability Eng System Saf. 2025;256:110682.
Artificial intelligence (AI) and machine learning (ML) are being used and tested in numerous ways. This review highlights how they are being used to detect and mitigate human error in safety-critical industries, the limitations and challenges of AI/ML, and insights from the recent literature. Examples from health care include using AI to detect diagnostic errors and combining AI with clinician expertise, with the ultimate decision to follow AI’s suggestion resting with the clinician.
National Action Alliance for Patient and Workforce Safety. January 21, 2025, 12:00 - 1:00 PM (eastern).
Health information technology implementation and use can introduce variables into care processes that can affect safety. This session will highlight recently updated SAFER guides designed to help healthcare organizations conduct proactive reviews to determine safety and effectiveness of electronic health record operations.
Fact Sheet/FAQs
Centers for Medicare and Medicaid Services. 2024.
As one element of a national program to improve care quality, the Centers for Medicare and Medicaid Services (CMS) has developed a three-point plan to guide efforts toward zero preventable harm for the patients they serve. The elements include promoting transparency, supporting safe cultures through partnership, and encouraging improvement through payment reform.
Book/Report
Health Services Safety Investigations Body; 2024.
Omitted or delayed medication therapy can contribute to patient discomfort, stress, and harm. This series of reports, to be developed over 2024-2025, examines factors at different points in the medication administration process that contribute to medications not being provided reliably to support safe patient care. The first report in the series covered factors present in NHS emergency departments that influence timely medication administration.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Jaenic Lee, MD, Josh Fernelius, MD and William Frick, MD |
A 55-year-old woman with a history of panic attacks, obesity, and untreated hypertension, experienced syncope after feeling flushed and lightheaded. On arrival at the emergency department, she had severely elevated blood pressure and hypoxemia. Diagnostic tests revealed acute heart failure exacerbation with pulmonary edema, marked elevation of brain natriuretic peptide (BNP), and elevated troponin-I. Despite treatment with diuretics and antihypertensives, her condition deteriorated, leading to intubation due to respiratory failure and subsequent cardiac arrest; cardiopulmonary resuscitation resulted in with return of spontaneous circulation. However, she suffered from ischemic stroke and intracranial hemorrhages, ultimately leading to a transition to comfort care and subsequent death. The commentary discusses the contraindications for beta-blockers in the setting of acute decompensated heart failure and appropriate treatment for hypertensive emergencies in the emergency department and intensive care unit.
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
Spotlight Case
Jonathan A. Edlow, MD, FACEP |
A patient in his mid-30s presented to the emergency department (ED) with three weeks of intermittent left-sided headaches, balance issues, and one brief episode of difficulty speaking and moving. On exam, the patient had normal vital signs, neurologic exam, and initial imaging; he was discharged from the ED without consultation from neurology. A few hours later, he suffered a stroke due to left posterior cerebral artery occlusion and vertebral artery dissection, leading to severe neurological deficits after delayed treatment. The commentary highlights the importance of thorough neurological investigation of patients presenting with dizziness and other simultaneous neurological symptoms, the challenges of diagnosing transient ischemic attack (TIA) – particularly in a young, healthy adult, and the limitations of non-contrast brain CT for identifying TIA or early ischemic strokes in patients presenting with dizziness.
This Month’s Perspectives
Interview
Patricia Dykes, PhD, MA, RN, FAAN, FACMI, Zoe Sousane, BS, Sarah E. Mossburg, RN, PhD |
Dr. Patricia Dykes is the Program Director for Research at the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital and a Professor of Medicine at Harvard Medical School. We spoke with her about falls and fall prevention.
Perspective
Patricia Dykes, PhD, MA, RN, FAAN, FACMI, Zoe Sousane, BS, Sarah E. Mossburg, RN, PhD |
This piece discusses the continuing challenge of preventing falls and explores strategies for preventing falls and falls with injury in both inpatient and outpatient settings.
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