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November 20, 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
Faugno E, Galbraith AA, Walsh KE, et al. BMJ Qual Saf. 2024;Epub Nov 4.
Historically, underserved racial and ethnic populations have been disproportionately affected by delayed diagnosis. In this review of quantitative studies conducted in the US, patients and caregivers in underserved communities reported several factors contributing to delayed diagnosis. Socioeconomic and sociocultural factors included healthcare avoidance, stigma, and distrust in the healthcare system. Health system factors included poor organizational health literacy and provider-related factors such as cognitive biases. There was a lack of research on diagnosis of chronic conditions, and no studies focused on Asian Americans and Pacific Islanders.
Li LZ, Yang P, Singer SJ, et al. JAMA Netw Open. 2024;7(11):e2443059.
Nurse burnout increased during the pandemic and remains prevalent. This review sought to determine the association between nurse burnout and patient safety, patient satisfaction, and quality of care. Nurse burnout increased over time and was negatively associated with these factors. The association between the subcomponents of burnout (e.g., safety culture, emotional exhaustion, and depersonalization) and lower health care quality, safety and patient satisfaction is also presented.
Wahlstedt E, Levy BE, Scott E, et al. J Patient Saf. 2024;Epub Oct 18.
The root cause analysis or RCA2 framework is a standardized approach to identify patient safety incidents based on their potential harm and frequency. In this study, researchers used an RCA2 algorithm to identify high-risk events for root cause analysis. Among 104 cases identified from the VA health system, the algorithm recommended nearly 57% for RCA. In comparison, only 17% of cases met the current institutional selection process, missing 45 potential high-frequency, high-harm events.
VanGompel EW, Singh L, Carlock F, et al. Ann Fam Med. 2024;22(5):375-382.
Rural care settings face unique challenges in the provision of safe obstetric care. This study explored whether the presence of family medicine (FM) physicians (who are more likely to attend births in rural settings without access to obstetricians or midwives) impacts safety culture and perinatal outcomes. Researchers surveyed 849 clinicians from 39 hospitals in Iowa and found that FM-only hospitals had a lower risk of cesarean deliveries, more support for vaginal birth, and stronger safety culture compared to hospitals with both FM physicians and obstetricians.
Barabucci G, Shia V, Chu ES, et al. NEJM AI. 2024;1(11):AIcs2400502.
Collective intelligence (e.g., collaboration of multiple providers to come to a final diagnosis) has been shown to produce a more accurate diagnosis than even the group’s most senior member. This study applied methods of collective intelligence to four large language models (LLM). The collective diagnosis was more accurate than individual LLMs, even when the highest performing LLM was removed. The authors suggest aggregating diagnoses from multiple LLMs may increase clinician trust in the response and mitigate reliance on a sole LLM or vendor.
White AA, Gallagher TH, Osinska PH, et al. Ann Intern Med. 2024;Epub Nov 5.
Concerns have been raised about the need to assess the clinical skills of aging physicians. This mixed-methods study of 21 physician leaders explored perspectives about mandatory competency screening of late-career physicians (those working beyond age 65 to 75) across 18 healthcare organizations in the United States. Findings suggest that competency assessment policies are all rooted in ensuring patient safety but vary in testing requirements, funding, decision-making processes, and appeal procedures.
Best NC, Nichols AO, Pierre-Louis B, et al. J Sch Nurs. 2024;40(5):504-513.
As non-healthcare settings, schools face unique challenges ensuring medication safety. In this longitudinal analysis of medication administration in North Carolina public schools (elementary, middle, and high schools), the number of medication errors and corrective action plans increased over time (2012-2018). Results indicate that medication errors increased when there were more schools in the district for nurses to cover. Only half of school nurses held a national certification in school nursing.
VanGompel EW, Singh L, Carlock F, et al. Ann Fam Med. 2024;22(5):375-382.
Rural care settings face unique challenges in the provision of safe obstetric care. This study explored whether the presence of family medicine (FM) physicians (who are more likely to attend births in rural settings without access to obstetricians or midwives) impacts safety culture and perinatal outcomes. Researchers surveyed 849 clinicians from 39 hospitals in Iowa and found that FM-only hospitals had a lower risk of cesarean deliveries, more support for vaginal birth, and stronger safety culture compared to hospitals with both FM physicians and obstetricians.
Metersky ML, Rodrick D, Ho S-Y, et al. JAMA Netw Open. 2024;7(11):e2442936.
Previous studies have found that the COVID-19 pandemic threatened patient safety due to several factors, including staffing and equipment shortages. This study of Medicare beneficiaries found that higher COVID-19 hospital burden was associated with a 23% higher risk of in-hospital adverse events among patients with and without COVID-19.
Wahlstedt E, Levy BE, Scott E, et al. J Patient Saf. 2024;Epub Oct 18.
The root cause analysis or RCA2 framework is a standardized approach to identify patient safety incidents based on their potential harm and frequency. In this study, researchers used an RCA2 algorithm to identify high-risk events for root cause analysis. Among 104 cases identified from the VA health system, the algorithm recommended nearly 57% for RCA. In comparison, only 17% of cases met the current institutional selection process, missing 45 potential high-frequency, high-harm events.
Adkins S, Alta’any R, Brar K, et al. J Med Educ Curric Dev. 2024;11:23821205241272358.
Many physicians report making at least one error during their careers, therefore coping with errors is an important skill for them to learn. In this intervention, family medicine residents attended three 1-hour didactic sessions featuring guided reflection following mentor storytelling, small group discussion, role play, and self-reflection. Self-efficacy and awareness increased following the intervention but did not reach statistical significance.
Lang Y, Chen K-Y, Zhou Y, et al. Interact J Med Res. 2024;13:e58635.
Patient participation in their own care is promoted as an important safety strategy. In this study, participants were asked to rate the importance and reasonableness of eight safety behaviors promoted by healthcare professionals: bringing medications to office visits, confirming medications at home, managing medication refills, using patient portals, organizing medications, checking medications, getting help, and knowing medications. Confirming medications was rated as the most important behavior, and knowing medications was rated as most reasonable. Using patient portals was rated as lowest in importance and reasonableness. Participants 65 and older reported higher importance and reasonableness of all eight safety behaviors than younger participants.
Baldwin CA, Krumm AM. AORN J. 2024;120(3):144-154.
The use of peer messengers to provide feedback regarding unprofessional behavior has been shown to be an effective way to improve the work environment, transparency, and accountability. This article describes critical elements for successful implementation of a peer messenger program as part of the Coworker Observation Reporting System. Requirements include socializing the concept and aligning behavioral expectations with the organization's norms or credo and selecting respected informal leaders as messengers.
Hallett N, Dickinson R, Eneje E, et al. Int J Nurs Stud. 2024;161:104923.
Mental health inpatients are a vulnerable population and have reported negative experiences while receiving inpatient psychiatric care. This systematic review highlights adverse or negative experiences reported by current or former inpatients. Across 111 studies, patients reported an imbalance of power, feeling traumatized or retraumatized, and poor coordination during care transitions.
Faugno E, Galbraith AA, Walsh KE, et al. BMJ Qual Saf. 2024;Epub Nov 4.
Historically, underserved racial and ethnic populations have been disproportionately affected by delayed diagnosis. In this review of quantitative studies conducted in the US, patients and caregivers in underserved communities reported several factors contributing to delayed diagnosis. Socioeconomic and sociocultural factors included healthcare avoidance, stigma, and distrust in the healthcare system. Health system factors included poor organizational health literacy and provider-related factors such as cognitive biases. There was a lack of research on diagnosis of chronic conditions, and no studies focused on Asian Americans and Pacific Islanders.
Li LZ, Yang P, Singer SJ, et al. JAMA Netw Open. 2024;7(11):e2443059.
Nurse burnout increased during the pandemic and remains prevalent. This review sought to determine the association between nurse burnout and patient safety, patient satisfaction, and quality of care. Nurse burnout increased over time and was negatively associated with these factors. The association between the subcomponents of burnout (e.g., safety culture, emotional exhaustion, and depersonalization) and lower health care quality, safety and patient satisfaction is also presented.
No results.
Rockville, MD: Agency for Healthcare Research and Quality; 2024. AHRQ Pub. No. 24-0088
Medication safety is a persistent challenge across health care. This NPSD Chartbook represents a comprehensive look at reported medication and other substance events, outlining data such as when in the process errors occur, human contributors to incidents and percentages of these events resulting in patient harm. The Chartbook identifies patterns in medication or other substance-related patient safety concerns and provides insights on how to mitigate related patient safety risks to reduce harm nationally.
Newspaper/Magazine Article
Terry K. WebMD. November 11, 2024;
Patients are partners in health care and can inform actions to identify a quick, accurate diagnosis and receive the care they need. This article introduces why diagnostic errors happen, commonly misdiagnosed conditions, and strategies for patients to participate in the process to ensure it is safe and effective.
Multi-use Website
London, England.
A national review of system characteristics in the UK found gaps in the NHS’s ability to listen to and learn from patients. The office of the Patient Safety Commissioner was established to address that gap. The site hosts annual reports, initiative updates and patient stories of harm. The recently released patient safety principles are designed to support just culture implementation and learning building blocks to guide development of patient engagement and improvement efforts.
Multi-use Website
Patients for Patient Safety US.
Large-scale survey efforts capture data that provides intelligence on both the current state of initiatives and avenues for improvement. This project is working to craft queries to be added to existing quality care survey instruments to enrich knowledge of the patient experience in healthcare safety, diagnosis, and discrimination. The project seeks input from patients and clinicians to identify questions for consideration.
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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