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May 22, 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
Estrada LV, Barcelona V, Dhingra L, et al. JAMA Netw Open. 2024;7:e249312.
Systemic racism and discrimination negatively impact the health of historically marginalized people. In this cross-sectional study of nursing home (NH) residents with severe cognitive impairment, historically marginalized residents had greater incidence of potentially avoidable hospitalizations compared to their white counterparts. Not only did the study identify racial and ethnic disparities at the national level, but also at the individual NH level.
Mamede S, Zandbergen A, de Carvalho-Filho MA, et al. BMJ Qual Saf. 2024;Epub Feb 16.
Anchoring bias occurs when a physician relies on their initial diagnostic impression despite subsequent information to the contrary. This study assessed the influence of disease knowledge on susceptibility to anchoring bias. In simulated case studies, physicians with higher disease knowledge were less likely than lower knowledge physicians to be biased by salient distracting features (e.g., patient presenting problem description with or without mention of family history of unrelated disease).
Valkonen V, Saano S, Haatainen K, et al. J Patient Saf. 2024;20:259-266.
Voluntary incident reporting data can provide unique insights into errors and opportunities to improve patient safety. This study used an enhanced free-text search method to identify the medication error (ME) reports involving substances commonly involved in medication errors (e.g., oxycodone, Warfarin). This approach increased the number of identified ME reports involving the specified medications and identified additional findings, such as inadequate pain management and duplicate prescriptions.
Valkonen V, Saano S, Haatainen K, et al. J Patient Saf. 2024;20:259-266.
Voluntary incident reporting data can provide unique insights into errors and opportunities to improve patient safety. This study used an enhanced free-text search method to identify the medication error (ME) reports involving substances commonly involved in medication errors (e.g., oxycodone, Warfarin). This approach increased the number of identified ME reports involving the specified medications and identified additional findings, such as inadequate pain management and duplicate prescriptions.
Sinnott C, Alboksmaty A, Moxey JM, et al. Br J Gen Pract. 2024;74:e339-e346.
Operational failures (e.g., distractions, situational constraints) can impact the delivery of safe, high-quality healthcare. This study, including general practitioners and patients in the UK National Health Service (NHS), used a modified Delphi process to prioritize operational failures in general practice. Participants identified several areas for improvement, including missing test results and inaccuracies in medical records.
Jaakkola M, Lemmetty S, Collin K, et al. Learn Org. 2024;31:337-357.
Organizational learning is a continuous process of integrating data and knowledge to ensure improvement. This qualitative study focuses on the starting points and presuppositions of organizational learning within a surgical department. Starting points for individual learning were informal and based on day-to-day work (e.g., solving a specific problem) and organizational learning encompassed more formal and intentional practices. Factors presupposing and framing the learning process can be divided into four categories: leadership and roles, practices and resources, collaboration and climate, and motivation and activity.
Abboudi E, Baron SW, Goriacko P, et al. Am J Health Syst Pharm. 2024;81:361-369.
Smart pump dose error reduction systems (DERS) alert users to unsafe medication administration orders. This article describes a performance improvement project to increase utilization of smart pump DERS technology and decrease manual order entry, which is vulnerable to human errors. Use of DERS increased from 77% of administered IV medications to 83%. The most effective intervention was adding a DERS problem reporting tool to the medication administration record.
Estrada LV, Barcelona V, Dhingra L, et al. JAMA Netw Open. 2024;7:e249312.
Systemic racism and discrimination negatively impact the health of historically marginalized people. In this cross-sectional study of nursing home (NH) residents with severe cognitive impairment, historically marginalized residents had greater incidence of potentially avoidable hospitalizations compared to their white counterparts. Not only did the study identify racial and ethnic disparities at the national level, but also at the individual NH level.
Mamede S, Zandbergen A, de Carvalho-Filho MA, et al. BMJ Qual Saf. 2024;Epub Feb 16.
Anchoring bias occurs when a physician relies on their initial diagnostic impression despite subsequent information to the contrary. This study assessed the influence of disease knowledge on susceptibility to anchoring bias. In simulated case studies, physicians with higher disease knowledge were less likely than lower knowledge physicians to be biased by salient distracting features (e.g., patient presenting problem description with or without mention of family history of unrelated disease).
Rotenstein L, Wang H, West CP, et al. Jt Comm J Qual Patient Saf. 2024;Epub Mar 14.
Team-based care is one approach to addressing the increasing burden of burnout among clinicians. Based on survey findings from 968 practicing physicians, higher perceptions of teamwork climate and safety climate were associated with lower odds of burnout. The researchers also found that physicians practicing in academic medical centers had lower odds of burnout compared to those working in private practice, after controlling for teamwork climate and safety climate.
Burus T, Lei F, Huang B, et al. JAMA Oncol. 2024;10:500-507.
Many people delayed care or were unable to get care during the first year of the COVID-19 pandemic. This study estimates the missed diagnoses of screenable cancers from March to December 2020. Diagnoses of included cancers were 6% lower than would be expected, even 10 months after the start of the pandemic. The greatest decrease was seen in prostate cancer, followed by breast and lung cancers, with an overall estimate of more than 134,000 missed cancer diagnoses.
Singh HK, Claeys KC, Advani SD, et al. Infect Control Hosp Epidemiol. 2024;45:405-411.
Healthcare-associated infections (HAIs) remain a common complication during inpatient care. This article summarizes diagnostic stewardship strategies to reduce the occurrence of HAIs and contrasts a patient-centered approach to diagnostic stewardship (focused on improving patient care) with a metric-centered approach (focused on reducing HAI rates through changes in diagnostic testing).
Holtsmark C, Larsen MH, Steindal SA, et al. J Clin Nurs. 2024;Epub May 6.
As part of the rapid response team (RRT), critical care nurses (CCN) serve as team leaders to prevent patient deterioration. This review identified three themes regarding the ways critical care nurses experience being part of the RRT team: balancing between confidence and fear in clinical encounters, facilitating collaboration, and managing challenging power dynamics in decision-making.
Finn M, Walsh A, Rafter N, et al. BMJ Open Qual. 2024;13:e002506.
Along with improvements to patient safety, interventions to optimize safety culture can also improve staff outcomes. This review highlights the effects safety culture interventions have on hospital staff, what may explain these effects, and how staff experience these changes. Teamwork and collaboration, leadership support for safety, and just culture were the most reported themes.
Capper T, Ferguson B, Muurlink O. Women Birth. 2024;37:101593.
Staff reports are important in identifying and addressing problems. This review highlights the experiences of staff who raised concerns about patient safety threats in maternal and neonatal care. Structural power, perfectionism, and bravery, hope, and disappointment were identified as overall themes regarding the decision to speak up. Notably, the majority of included studies were from the United Kingdom, highlighting the need for other regions to conduct similar research.
No results.
Knees M, Raffel KE, Kissler M, et al. Cognitive Load Theory and its Impact on Diagnostic Accuracy. Rockville, MD: Agency for Healthcare Research and Quality; May 2024. Publication No. 24-0010-2-EF.
Cognition plays a crucial role in how clinicians perceive, interpret, and integrate information during the diagnostic process. This AHRQ issue brief summarizes key concepts of cognitive load theory (CLT), describes the relationship between CLT and diagnostic accuracy, and provides recommendations for future efforts to optimize cognition and decrease diagnostic errors.
Rockville, MD: Agency for Research and Quality; May 9, 2024. Notice Number NOT-HS-24-014.
Health systems are increasingly developing, testing, and deploying artificial intelligence (AI) to support patient care. This upcoming funding opportunity will focus on assessing the impact, both positive and negative, of actual AI deployments in healthcare delivery systems and how that impact can be affected by implementation and use strategies. The estimated publication date is late spring/early summer 2024.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute Care. 2024;29(9):1-4.
Pharmacogenomics (PGx) refers to the impact of genetic variation on an individual’s response to medications. This article describes how one children’s hospital is using PGx to reduce adverse drug reactions and outlines recommendations for implementing a PGx testing program.
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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