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May 8, 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
Hedqvist A‐T, Praetorius G, Ekstedt M, et al. J Adv Nurs. 2024;Epub Apr 20.
Transitions of care are a vulnerable time for all patients and especially older adults with complex care needs. Utilizing document review, observations, and interviews, this study describes how inconsistencies in timing and precision at the time of transition put patients at risk. Examples include early discharge from hospital due to crowding, insufficient assessment of activities of daily living, and incomplete transfer of information. A safe care transition pathway describes critical steps to ensure safe transitions.
Rydzewski NR, Dinakaran D, Zhao SG, et al. NEJM AI. 2024;1:AIoa2300151.
Large language models (LLM) are being developed to improve diagnostic accuracy. This study compared five LLMs on their accuracy of oncology diagnoses. Accuracy ranged from no better than random chance to similar to resident physicians. Notably, all models exhibited poor performance on women-predominant malignancies, suggesting a bias in training materials. This highlights the importance of partnerships between developers and medical professionals to co-develop reliable training sets.
Schiavo G, Forgerini M, Varallo FR, et al. Res Social Adm Pharm. . 2024;Epub Mar 22.
Adverse drug events (ADE) are common in older adults. This systematic review identified 12 trigger tools for detecting ADE in older adults. Trigger tools designed or adapted for the older adult population performed better than those designed for the general population. Most studies assessed performance using positive predictive value (PPV), but there was no consensus of what constitutes a good or poor PPV.
Motamedi M, Degeling C, M. Carter S. BMC Health Serv Res. 2024;24:436.
Women patients experience medical gaslighting wherein clinicians, policy makers, or the public do not believe their lived experiences. This article details more than 400 accounts submitted by women who were harmed by transvaginal mesh, and how their harm was exacerbated by dismissals by their physicians and regulatory bodies.
Goldhaber NH, Mehta S, Longhurst CA, et al. BMJ Open Quality. 2024;13:e002453.
Poor communication between team members is associated with poorer patient outcomes. To improve team communication in the operating room (OR), in one health system, personalized surgical caps with name and role were distributed to all perioperative staff. Before and after the caps were distributed, the highest mean survey score was for the item "knowing the name of an interdisciplinary team member is important for patient care." Patient outcomes (e.g., surgical site infections, return to OR) did not change during the study period, however, 72% of perioperative staff indicated they would like the hospital to continue providing named surgical caps.
Rydzewski NR, Dinakaran D, Zhao SG, et al. NEJM AI. 2024;1:AIoa2300151.
Large language models (LLM) are being developed to improve diagnostic accuracy. This study compared five LLMs on their accuracy of oncology diagnoses. Accuracy ranged from no better than random chance to similar to resident physicians. Notably, all models exhibited poor performance on women-predominant malignancies, suggesting a bias in training materials. This highlights the importance of partnerships between developers and medical professionals to co-develop reliable training sets.
Hedqvist A‐T, Praetorius G, Ekstedt M, et al. J Adv Nurs. 2024;Epub Apr 20.
Transitions of care are a vulnerable time for all patients and especially older adults with complex care needs. Utilizing document review, observations, and interviews, this study describes how inconsistencies in timing and precision at the time of transition put patients at risk. Examples include early discharge from hospital due to crowding, insufficient assessment of activities of daily living, and incomplete transfer of information. A safe care transition pathway describes critical steps to ensure safe transitions.
Mangus CW, James TG, Parker SJ, et al. Jt Comm J Qual Patient Saf. 2024;Epub Mar 12.
The emergency department (ED) presents unique challenges in making and communicating an accurate diagnosis. This study sought perspectives of patients, nurses, and physicians about diagnostic vulnerabilities faced in the ED and suggested interventions. All three groups proposed that inter- and intrateam communication could be improved, for example with structured hand-offs between emergency medical services and the ED, and between members of the care team.
Motamedi M, Degeling C, M. Carter S. BMC Health Serv Res. 2024;24:436.
Women patients experience medical gaslighting wherein clinicians, policy makers, or the public do not believe their lived experiences. This article details more than 400 accounts submitted by women who were harmed by transvaginal mesh, and how their harm was exacerbated by dismissals by their physicians and regulatory bodies.
Hinton L, Dakin FH, Kuberska K, et al. BMJ Qual Saf. . 2024;Epub Apr 24.
Telephone and video visits are increasingly common across all clinical areas, and research into their safety is still evolving. This study with pregnant/recently pregnant women, maternity providers, and system-level stakeholders details what does and does not work well during remote prenatal visits. Participants reported increased convenience (e.g., patients not having to miss work), but also described the visits as transactional with potentially less psychological safety for sharing concerns. Additional research is required to ensure safety and equity with remote visits.
Sama SR, Quinn MM, Gore RJ, et al. J Appl Gerontol. 2024;Epub Apr 23.
Patient or client homes present unique safety challenges. This study utilized motivational interviewing by nurse managers, videos, and a safety handbook to encourage home care recipients to create safer conditions in their homes for both themselves and home care aides. The most common improvement following the nurse manager visit was improved access into the home and a reduction in trip and fall hazards.
Sova PM, Holmström A-R, Airaksinen M, et al. Eur J Hosp Pharm. 2024;31:227-233.
Medication management encompasses several stages, including ordering, preparing, dispensing, administering, and monitoring. In this study, a hospital used Healthcare Failure Mode and Effect Analysis (HFMEA) to prospectively identify risks and propose solutions when implementing a new electronic medication management system. Fifteen recommendations were made, namely ensuring correct patient identification during ordering and administration.
Newman-Toker DE, Sharfstein JM. JAMA Health Forum. 2024;5:e241339.
Artificial intelligence (AI) is seen as a primary innovation that will improve the safety and quality of health care, yet it has its detractors. This commentary explores the importance of effective policy to guide the development, training, and use of chatbots, large language models, and other elements of AI to improve its accuracy as a diagnostic tool.
Schiavo G, Forgerini M, Varallo FR, et al. Res Social Adm Pharm. . 2024;Epub Mar 22.
Adverse drug events (ADE) are common in older adults. This systematic review identified 12 trigger tools for detecting ADE in older adults. Trigger tools designed or adapted for the older adult population performed better than those designed for the general population. Most studies assessed performance using positive predictive value (PPV), but there was no consensus of what constitutes a good or poor PPV.
Ippolito M, Einav S, Giarratano A, et al. Br J Anaesth. 2024;Epub Apr 19.
Clinician fatigue is widely viewed as a risk to patient safety. This review summarizes research of fatigue in anesthesiologists. Anesthesiologists perceive longer shift length and overnight shifts negatively impact patient safety. Even in countries that have adopted legislation to limit shift length, anesthesiologists frequently reported working longer than allowed and not getting the full rest period between shifts. A culture that fosters awareness and prevention of fatigue can improve not only patient safety, but also physician well-being.
Brook K, Agarwala AV, Tewfik GL. J Patient Saf. 2024;Epub Mar 13.
Morbidity and mortality (M&M) conferences have long been part of medical learning. This commentary describes the historical "blame and shame" nature of early M&M conferences and outlines processes to shift them to a just culture. The ideal M&M conference should have a robust case selection process with a focus on system errors, a clear structure, and defined goals with an interdisciplinary and interprofessional audience.
Graafsma J, Murphy RM, van de Garde EMW, et al. J Am Med Inform Assoc. 2024;Epub Apr 19.
Clinical decision support systems (CDSS) are widely used to prevent adverse drug events (ADE) but can generate alerts with low clinical relevance resulting in alert fatigue and high override rates. This review summarizes existing research in the use of artificial intelligence (AI) to reduce alert fatigue in CDSS. Included studies reported AI decreased inappropriate alerts. However, none of the studies reported external validation or transparency of model development.
No results.
Audiovisual
Scott M. The Pulse. New York Public Radio; April 26, 2024.
Individuals involved in medical errors need time and support to process the incident and its consequences. This moderated podcast examines how clinicians, leaders, and patients and families respond after a patient safety event. The discussions are anchored in aptly-told stories of harm, courage, and investigation.
Multi-use Website
National Quality Forum.
Strong incident reporting systems are a foundational component for understanding preventable health care error. This initiative will work to enhance the reporting and measurement of serious reportable events (SREs) through the definition of standards to homogenize data collection across a range of established health care incident collection systems.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Eric Signoff, MD, Noelle Boctor, MD, and David K. Barnes, MD, FACE |
A 61-year-old patient presented to the emergency department (ED) complaining of weakness with findings of shuffling gait, slurred speech, delayed response to questions, and inability to concentrate or make eye contact. A stroke alert was activated and a neurosurgeon evaluated the patient via teleconsult. There was no intracranial hemorrhage identified on non-contrast computed tomography (CT) of the head and the neurosurgeon recommended administering Tenecteplase (TNKase). Thirty minutes after TNKase administration, laboratory tests showed that the patient’s alcohol level was 433 mg/dL, a potentially fatal level. The patient was admitted to the intensive care unit (ICU) for close monitoring. A repeat CT scan was performed and revealed a new subdural hemorrhage. The neurosurgeon was updated, conservative treatment was recommended, and the patient recovered slowly. The commentary highlights how “stroke chameleons,” “stroke mimics,” and biases contribute to stroke misdiagnosis and strategies to identify “stroke mimics” and improve stroke diagnosis.
WebM&M Cases
Spotlight Case
Christian Bohringer, MBBS, Manuel Fierro, MD, and Sandhya Venugopal, MD |
A 77-year-old man was admitted for coronary artery bypass graft surgery with aortic valve replacement. The operation went smoothly but the patient went into atrial fibrillation with hypotension during removal of the venous cannula. The patient was shocked at 10 Joules but did not convert to sinus rhythm; the surgeon requested 20 Joules synchronized cardioversion, after which the patient went into ventricular fibrillation and was immediately and successfully defibrillated with 20 Joules. While the patient was being transferred to his gurney, the operating room team noticed that the electrocardiogram cable that enables synchronized cardioversion was only connected into the anesthesia monitor and was never connected to the patient’s defibrillator. The commentary discusses the risks of unsynchronized shocks or pacing, the role of standardized processes to ensure that operating room equipment is prepared and set-up correctly, and the importance of operating room team preparation to urgently address life threatening complications
WebM&M Cases
Anita Singh, MD and Cecilia Huang, MD |
An 82-year-old woman presented to the emergency department for evaluation of “altered mental status” after falling down 5 step-stairs at home. She had a Glasgow Coma Score of 11 (indicating decreased alertness) on arrival. Computed tomography (CT) of the head revealed a right thalamic hemorrhage. She was admitted to the Vascular Neurology service. Overnight, the patient developed atrial fibrillation with rapid ventricular rate (RVR), which required medications for rate control. The patient failed her swallow evaluation by speech therapy; therefore, a nasogastric (NG) tube was inserted through her right nostril, without difficulty or complications, to administer oral medications. A chest radiograph was obtained to verify placement, but the resident physician did not review the images. During nursing shift change, the incoming nurse was told that the NG tube was ready for use. A tablet of metoprolol 25 mg was crushed by the nurse, mixed with water, and administered through the NG tube. A few minutes after administration, the patient was found to be somnolent and hypoxemic, with oxygen saturation around 80%, requiring supplemental oxygen via non-rebreather mask. Chest radiography showed that the NG tube was in the right lung. The commentary underscores the importance of confirming proper placement of NG tubes before administering feedings, fluids or medications and strategies to reduce the risk of tube placement errors.
This Month’s Perspectives
Interview
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCT |
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCT, is the Director of Nursing Programs at the American Nurses Association and Adjunct Professor at the University of Maryland School of Nursing and the Frances Payne Bolton School of Nursing at Case Western Reserve University. We spoke to her about patient safety amid nursing workforce challenges.
Perspective
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD |
This piece focuses on changes in the nursing workforce over recent years, including nursing shortages. Patient safety challenges may arise from these workforce challenges, but those challenges can also be mitigated.
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