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February 26, 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
Congdon M, Rasooly IR, Toto RL, et al. Pediatr Qual Saf. 2024;9(6):e773.
Diagnostic reasoning is a core component of safe care but is not always included in formal educational curricula. In this study, learners, attending physicians, and education leaders shared their experiences learning about or teaching diagnostic reasoning to inform development of a diagnostic reasoning curriculum. Learners and educators highlighted the importance of psychological safety to reporting missed diagnosis or diagnostic uncertainty, integrating the curriculum into existing educational programming, and faculty development on the topic.
Nunes E, Sirtoli F, Lima E, et al. Healthcare. 2024;12(20):2075.
Measuring patient safety is essential to ensuring healthcare organizations are providing safe, high-quality care. This scoping review includes 63 studies that collectively reported on 47 instruments or scales used to assess patient safety in healthcare. These tools evaluated 71 dimensions of patient safety, including teamwork, safety climate, and communication. The authors note that the diversity of measurement tools and dimensions may hinder benchmarking efforts within and between healthcare organizations.
Wagner CM, Joynt Maddox KE, Ailawadi G, et al. JAMA Surg. 2024;160(1):29-36.
Failure-to-rescue (FTR) refers to the idea that many complications of medical care are not preventable and that healthcare systems should be able to rapidly identify and treat complications when they occur. In a retrospective study of Medicare beneficiaries from 2015 to 2020, researchers found that female patients undergoing high-risk surgeries had rates of complications similar to male patients but higher 30-day mortality and failure-to-rescue rates. These findings highlight a gender disparity in perioperative care and the need for better recognition and management of clinical deterioration in female patients.
Handley JL, Krevat SA, Fong A, et al. NPJ Digit Med. 2024;7(1):351.
Patient safety reports submitted to the Food and Drug Administration’s (FDA) Manufacturer and User Facility Device Experience (MAUDE) database provide a rich source for identifying how artificial intelligence/machine learning (AI/ML) may have contributed to the event. This study identified 429 safety reports associated with AI/ML-enabled medical devices; one-quarter were potentially related to AI/ML, underscoring the need for an AI patient safety program.
Congdon M, Rasooly IR, Toto RL, et al. Pediatr Qual Saf. 2024;9(6):e773.
Diagnostic reasoning is a core component of safe care but is not always included in formal educational curricula. In this study, learners, attending physicians, and education leaders shared their experiences learning about or teaching diagnostic reasoning to inform development of a diagnostic reasoning curriculum. Learners and educators highlighted the importance of psychological safety to reporting missed diagnosis or diagnostic uncertainty, integrating the curriculum into existing educational programming, and faculty development on the topic.
Eckhouse SR, Huston M, Smith ER, et al. J Am Coll Surg. 2025;240(2):148-157.
Peer messenger programs have been shown to be effective at reducing unprofessional behavior. This article describes the development, implementation, and sustainment of a peer advocate (PA) program for operating room staff who report unprofessional behavior in a team member. The goal of the program is to reduce unprofessional behavior and repair damaged relationships. In the program's first two years, 39 instances of unprofessional behavior were reported, with more than half successfully resolved through the PA program without further escalation to leadership or human resources.
Wagner CM, Joynt Maddox KE, Ailawadi G, et al. JAMA Surg. 2024;160(1):29-36.
Failure-to-rescue (FTR) refers to the idea that many complications of medical care are not preventable and that healthcare systems should be able to rapidly identify and treat complications when they occur. In a retrospective study of Medicare beneficiaries from 2015 to 2020, researchers found that female patients undergoing high-risk surgeries had rates of complications similar to male patients but higher 30-day mortality and failure-to-rescue rates. These findings highlight a gender disparity in perioperative care and the need for better recognition and management of clinical deterioration in female patients.
Lauricella M, Nene RV, Coyne CJ, et al. Am J Emerg Med. 2024;89:135-138.
Bias, including bias in clinical documentation, negatively impacts care of marginalized patients. In this study, emergency department (ED) physician notes were included if the patient had a history of unstable housing to establish if the use of the word "homeless" was associated with admission status and opioid prescription rates. Patients whose ED note contained the word "homeless" were more likely to be discharged rather than admitted and less likely to receive IV opioid medication.
Neyens L, Stouten E, Vanhaecht K, et al. J Patient Saf. 2025;21(1):9-14.
Clinicians who are involved in patient safety incidents often continue to experience psychological or emotional harm afterward. This cross-sectional study, which included 78 general practitioners in Belgium, found that 87% had been involved in a patient safety incident during their career. Over half reported being involved in an event in the prior year. Respondents reported emotional consequences (e.g., guilt, stress, shame). Only half of respondents were involved in an open discourse process after the incident, but participation in disclosure improved emotional outcomes.
Lounsbury O, Li E, Lunova T, et al. Health Policy Tech. 2025;14(1):100966.
While virtual care allowed continued access to primary care during the COVID-19 pandemic, it was not without risks. This study, conducted with patients and providers, identifies patient safety risks associated with virtual care and strategies patients and providers can implement to mitigate those risks. Patients and providers described limitations with describing and examining relevant symptoms, as patients might be unaware of what is important to report. They also reported technological and logistical barriers to care. Mitigation strategies include improving triage, providing technical support before and during the appointment, and standardizing guidelines to ensure continuity of care.
Viftrup A, Laustsen S, Pahle ML, et al. BMJ Open. 2024;14(11):e082807.
During the COVID-19 pandemic, elective surgical procedures were often canceled or postponed due to resource constraints. This cross-sectional study at one Danish hospital found that patients whose surgeries were canceled reported adverse physical and emotional outcomes, such as loneliness, anxiety, inability to perform activities of daily living, and the need for higher doses of pain medicine.
Burchell D, MacPhee S, Sinclair D, et al. Patient Saf Risk Manag. 2024;Epub Dec 26.
Root cause analysis (RCA) is a common investigation technique in healthcare. This study sought to understand staff perspectives on including in situ simulation as a component of RCA. Barriers included concerns over simulation being punitive, for example, to justify firing staff involved in the initial patient safety incident. Valuing patient safety and wanting to deliver safe care to patients lead staff and clinicians to favor the use of simulation.
Redelmeier DA, Roach J. J Hosp Med. 2024;Epub Dec 30.
Apologizing to the patient and family after a harmful event can benefit both patient and provider. This commentary uses three case studies on apologies to present insights into effective and ineffective strategies. Apologies that are sincere and accurate are most effective. Additionally, onlookers (e.g., friends, family) may have a different opinion about the apology. In one study, patients rated perfunctory apologies as more effective than no apology, but onlookers rated them as no different. Teaching and role-modeling how to apologize effectively is needed to reestablish trust in the patient-provider relationship.
Hunter MK, Singareddy C, Mundt KA. Front Public Health. 2024;12:1479750.
Diagnostic error continues to challenge patient safety. This narrative review presents ways to improve epidemiological research into diagnostic error. Definitions of "diagnostic error" vary greatly between studies. Instead of developing a standardized definition, the authors recommend considering how the timing and accuracy of a diagnosis impact its accuracy and validity. Other important considerations include data source (e.g., administrative claims, malpractice claims, autopsies), social determinants of health, patient access to care, and bias.
Nunes E, Sirtoli F, Lima E, et al. Healthcare. 2024;12(20):2075.
Measuring patient safety is essential to ensuring healthcare organizations are providing safe, high-quality care. This scoping review includes 63 studies that collectively reported on 47 instruments or scales used to assess patient safety in healthcare. These tools evaluated 71 dimensions of patient safety, including teamwork, safety climate, and communication. The authors note that the diversity of measurement tools and dimensions may hinder benchmarking efforts within and between healthcare organizations.
Gqaleni TM, Mkhize SW, Chironda G. J Med Internet Res. 2024;26:e48580.
Patient safety incident reporting and learning (PSIRL) systems are integral to ensuring patient safety. This review identified strategies for PSIRL implementation in specialized care units. Results suggest computer-based systems are more efficient than paper-based systems and increased the number of reports submitted and decreased errors. However, only 13 studies were identified, suggesting more research is needed into PSIRL in specialized care units.
No results.
No results.
This Month’s WebM&Ms
WebM&M Cases
Kristine Markham, PharmD, BCPPS and Maki Usui, PharmD, BCPPS, and Cady Smith BA |
Following an uncomplicated urologic surgery for hypospadias repair, a previously healthy 2-year-old boy was discharged with a 5-day course of hydrocodone-acetaminophen 7.5-325 mg/15 mL solution. The child was brought to the emergency department due to inconsolable crying. The ED workup was unremarkable, and he was sent home with a 4.6 day supply of oxycodone 1 mg/mL. Four days later, he became apneic, cyanotic, and unresponsive at home. Emergency first responders were called to the scene and the patient’s cardiac rhythm was determined to be pulseless electrical activity. They began cardiopulmonary resuscitation and administered naloxone and two doses of epinephrine. Upon arrival at the ED, continued resuscitation was unsuccessful, and the child was declared deceased. Inadvertent dose stacking and opioid polypharmacy may have contributed to this patient’s death.
WebM&M Cases
Spotlight Case
Samantha Brown, MD, Garth Utter, MD, MSc, and David K. Barnes, MD |
A man with a history of prior umbilical hernia repair presented to the emergency department (ED) with abdominal pain and was initially diagnosed with cholelithiasis before being discharged home. However, the next day he returned to another ED with similar symptoms and was diagnosed with a small bowel obstruction caused by adhesions from a ventral hernia. He underwent surgery but died three days later from multi-organ failure and sepsis caused by necrotic bowel and peritonitis. The commentary describes the appropriate evaluation for acute abdominal pain, the importance of imaging in patients with high-risk abdominal pain, and how to mitigate the influence of cognitive biases in the diagnostic process.
This Month’s Perspectives
Interview
Timothy Vogus, PhD; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD |
Timothy Vogus is the Brownlee O. Currey, Jr., Professor of Management at Vanderbilt University’s Owen Graduate School of Management. He is also a founding and continuing member of the Blue Ribbon Panel that developed Leapfrog Group's Hospital Safety Score.
Perspectives on Safety
Lucy A. Savitz, MBA, PhD; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD |
Dr. Lucy Savitz is a professor of health policy and management at the University of Pittsburgh School of Public Health. We spoke with her about learning systems and their impact on patient safety.
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