Issues

PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. 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.

Current Issue

April 1, 2020

Weekly Resource

Email Updates

RSS Feed

Organizational Policy/Guidelines

ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection.

American College of Radiology. ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection. March 11, 2020.

Study

Health and social care-associated harm amongst vulnerable children in primary care: mixed methods analysis of national safety reports.

Omar A, Rees P, Cooper A, et al. Arch Dis Child. 2020.

What do emergency department physicians and nurses feel? A qualitative study of emotions, triggers, regulation strategies, and effects on patient care.

Isbell LM, Boudreaux ED, Chimowitz H, et al. BMJ Qual Safety. 2020.

Incidence of wrong-site surgery list errors for a 2-year period in a single national health service board.

Geraghty A, Ferguson L, McIlhenny C, et al. J Patient Saf. 2020;16.

Adapting rapid assessment procedures for implementation research using a team-based approach to analysis: a case example of patient quality and safety interventions in the ICU.

Holdsworth LM, Safaeinili N, Winget M, et al. Implement Sci. 2020;15.

Listening and question-asking behaviors in resident and nurse handoff conversations: a prospective observational study.

Kannampallil T, Abraham J. J Am Med Inform Assoc. 2020.

Elder abuse and neglect: an overlooked patient safety issue. A focus group study of nursing home leaders' perceptions of elder abuse and neglect.

Myhre J, Saga S, Malmedal W, et al. BMC Health Serv Res. 2020;20.

Patient perspectives on the use of artificial intelligence for skin cancer screening: a qualitative study,

Nelson CA, Pérez-Chada LM, Creadore A, et al. JAMA Dermatol. 2020.

Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation.

Oliva EM, Bowe T, Manhapra A, et al. BMJ. 2020.

Uncertain diagnoses in a children's hospital: patient characteristics and outcomes.

Sump CA, Marshall TL, Ipsaro AJ, et al. Diagnosis. 2020.

Review

Rate of preventable mortality in hospitalized patients: a systematic review and meta-analysis.

Rodwin BA, Bilan VP, Merchant NB, et al. J Gen Intern Med. 2020.

Commentary

Two cultures in modern science and technology: for safety and validity does medicine have to update?

Becker RE. J Patient Saf. 2020;16.

Eleven basic procedures/practices for dental patient safety.

Perea-Pérez B, Labajo-González E, Acosta-Gío AE, et al. J Patient Saf. 2020;16.

What are we doing when we double check?

Pfeiffer Y, Zimmermann C, Schwappach DLB. BMJ Qual Saf. 2020.

What every health lawyer should know about the Patient Safety and Quality Improvement Act of 2005.

Hanzal M. J Health Life Sci Law. 2020;13.

Book/Report

Eliminating Medication Overload: A National Action Plan.

Working Group on Medication Overload. Eliminating Medication Overload: A National Action Plan. Brookline, MA: Lown Institute; 2020.

Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care. Executive Summary.

Maxwell J, Bourgoin A, Crandall J. Rockville, MD : Agency for Healthcare Research and Quality; 2020.

Effective Reporting Could Improve Safe Use of Electronic Health Records.

Effective Reporting Could Improve Safe Use of Electronic Health Records. Philadelphia, PA: Pew Charitable Trusts; March 2020.

Audiovisual Presentation

Unprofessional Behavior Leads to Complications.

JN Learning. 2020.

Toolkit

Improving Diagnosis and Treatment of Maternal Sepsis.

Improving Diagnosis and Treatment of Maternal Sepsis. Stanford, CA; California Maternal Quality Care Collaborative: Jan 22, 2020.

Newspaper/Magazine Article

Do you know what doses are being programmed in the OR? Make it an expectation to use smart infusion pumps with DERS.

ISMP Medication Safety Alert! Acute Care Edition. 2020;25.

Mask shortage straps pharmacists who need them to keep medicines pure.

Jewett C, Lupkin S. National Public Radio. 2020.

Past Issues

April 1, 2020

Weekly Resource

Email Updates

RSS Feed

Organizational Policy/Guidelines

ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection.

American College of Radiology. ACR Recommendations for the use of Chest Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection. March 11, 2020.

Study

Health and social care-associated harm amongst vulnerable children in primary care: mixed methods analysis of national safety reports.

Omar A, Rees P, Cooper A, et al. Arch Dis Child. 2020.

What do emergency department physicians and nurses feel? A qualitative study of emotions, triggers, regulation strategies, and effects on patient care.

Isbell LM, Boudreaux ED, Chimowitz H, et al. BMJ Qual Safety. 2020.

Incidence of wrong-site surgery list errors for a 2-year period in a single national health service board.

Geraghty A, Ferguson L, McIlhenny C, et al. J Patient Saf. 2020;16.

Adapting rapid assessment procedures for implementation research using a team-based approach to analysis: a case example of patient quality and safety interventions in the ICU.

Holdsworth LM, Safaeinili N, Winget M, et al. Implement Sci. 2020;15.

Listening and question-asking behaviors in resident and nurse handoff conversations: a prospective observational study.

Kannampallil T, Abraham J. J Am Med Inform Assoc. 2020.

Elder abuse and neglect: an overlooked patient safety issue. A focus group study of nursing home leaders' perceptions of elder abuse and neglect.

Myhre J, Saga S, Malmedal W, et al. BMC Health Serv Res. 2020;20.

Patient perspectives on the use of artificial intelligence for skin cancer screening: a qualitative study,

Nelson CA, Pérez-Chada LM, Creadore A, et al. JAMA Dermatol. 2020.

Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation.

Oliva EM, Bowe T, Manhapra A, et al. BMJ. 2020.

Uncertain diagnoses in a children's hospital: patient characteristics and outcomes.

Sump CA, Marshall TL, Ipsaro AJ, et al. Diagnosis. 2020.

Review

Rate of preventable mortality in hospitalized patients: a systematic review and meta-analysis.

Rodwin BA, Bilan VP, Merchant NB, et al. J Gen Intern Med. 2020.

Commentary

Two cultures in modern science and technology: for safety and validity does medicine have to update?

Becker RE. J Patient Saf. 2020;16.

Eleven basic procedures/practices for dental patient safety.

Perea-Pérez B, Labajo-González E, Acosta-Gío AE, et al. J Patient Saf. 2020;16.

What are we doing when we double check?

Pfeiffer Y, Zimmermann C, Schwappach DLB. BMJ Qual Saf. 2020.

What every health lawyer should know about the Patient Safety and Quality Improvement Act of 2005.

Hanzal M. J Health Life Sci Law. 2020;13.

Book/Report

Eliminating Medication Overload: A National Action Plan.

Working Group on Medication Overload. Eliminating Medication Overload: A National Action Plan. Brookline, MA: Lown Institute; 2020.

Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care. Executive Summary.

Maxwell J, Bourgoin A, Crandall J. Rockville, MD : Agency for Healthcare Research and Quality; 2020.

Effective Reporting Could Improve Safe Use of Electronic Health Records.

Effective Reporting Could Improve Safe Use of Electronic Health Records. Philadelphia, PA: Pew Charitable Trusts; March 2020.

Audiovisual Presentation

Unprofessional Behavior Leads to Complications.

JN Learning. 2020.

Toolkit

Improving Diagnosis and Treatment of Maternal Sepsis.

Improving Diagnosis and Treatment of Maternal Sepsis. Stanford, CA; California Maternal Quality Care Collaborative: Jan 22, 2020.

Newspaper/Magazine Article

Do you know what doses are being programmed in the OR? Make it an expectation to use smart infusion pumps with DERS.

ISMP Medication Safety Alert! Acute Care Edition. 2020;25.

Mask shortage straps pharmacists who need them to keep medicines pure.

Jewett C, Lupkin S. National Public Radio. 2020.

March 25, 2020

Periodic Issue

Email Updates

RSS Feed

Organizational Policy/Guidelines

Opioid guidelines for common dental surgical procedures: a multidisciplinary panel consensus.

Farooqi OA, Bruhn WE, Lecholop MK, et al. Int J Oral Maxillofac Surg. 2020;49.

Study

Errors during resuscitation: the impact of perceived authority on delivery of care.

Delaloye NJ, Tobler K, OʼNeill T, et al. J Patient Saf. 2020;16.

A protocol for the safe use of hazardous drugs in the OR.

Hemingway MW, Meleis L, Oliver J, et al. AORN J. 2020;111.

Detecting patient deterioration using artificial intelligence in a rapid response system.

Cho K-J, Kwon O, Kwon J-myoung, et al. Crit Care Med. 2020.

Analysis of patient-physician concordance in the understanding of chemotherapy treatment plans among patients with cancer.

Almalki H, Absi A, Alghamdi A, et al. JAMA Network Open. 2020;3.

Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association.

Soncrant C, Mills PD, Neily J, et al. J of Patient Saf. 2020;16.

Retrospective review for medication dose errors in pediatric emergency department medication orders that bypassed pharmacist review.

Todd SE, Thompson AJ, Russell WS. Pediatr Emerg Care. 2020.

Commentary

The cognitive health system.

Coiera E. Lancet. 2020;395.

Conspicuous by Its absence: diagnostic expert testing under uncertainty.

Dai T, Singh S. Market Sci. 2020.

Identifying adverse events: reflections on an imperfect gold standard after 20 years of patient safety research.

Shojania KG, Marang-van de Mheen PJ. BMJ Quality & Safety. 2020;29.

Training Programs

Taking action to close the loop on diagnostic error: a Constellation and SIDM Collaborative.

Society to Improve Diagnosis in Medicine. Taking action to close the loop on diagnostic error: a Constellation and SIDM Collaborative.

Government Resource

Patient Safety Improvement Act of 2020.

Patient Safety Improvement Act of 2020. SB 3380. 116th Congress (2020).

Newspaper/Magazine Article

Broken, fragmented health-care system failed daughter who died by suicide.

Klowak M. CBS News. 2020.

For 4 days, the hospital thought he had just pneumonia. It was coronavirus.

Goldstein J, Salcedo A. New York Times. 2020.

Book/Report

Patient Safety, Spring 2019 Final CDP Report.

Patient Safety Standing Committee. Patient Safety, Spring 2019 Final CDP Report. February 6, 2020. Washington DC; National Quality Forum. February 2020.

The threat within: mitigating the risk of medical error.

Bennett S. Springer International Publishing; 2020.

March 18, 2020

Periodic Issue

Email Updates

RSS Feed

Government Resource

Making Healthcare Safer III.

Holmes A, Long A, Wyant B, et al. Making Healthcare Safer III. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0029-EF.

Review

Adverse outcomes of polypharmacy in older people: systematic review of reviews.

Davies LE, Spiers G, Kingston A, et al. J Am Med Dir Assoc. 2020;21.

A systematic review exploring the content and outcomes of interventions to improve psychological safety, speaking up and voice behaviour.

O’Donovan R, McAuliffe E. BMC Health Serv Res. 2020;20.

Study

'Immunising' physicians against availability bias in diagnostic reasoning: a randomised controlled experiment.

Mamede S, de Carvalho-Filho MA, de Faria RMD, et al. BMJ Qual Saf. 2020.

Who gets the benefit of the doubt? Performance evaluations, medical errors, and the production of gender inequality in emergency medical education.

Brewer A, Osborne M, Mueller AS, et al. Am Sociol Rev. 2020.

Enhancing teamwork communication and patient safety responsiveness in a paediatric intensive care unit using the daily safety huddle tool.

Aldawood F, Kazzaz Y, AlShehri A, et al. BMJ Open Quality. 2020;9.

Analysis of pharmacist-identified medication-related problems at two United Kingdom hospitals: a prospective observational study.

Geeson C, Wei L, Franklin BD. International Journal of Pharmacy Practice. 2020.

A review of adverse event reports from emergency departments in the Veterans Health Administration.

Gill S, Mills PD, Watts BV, et al. Journal of Patient Safety. 2020.

Ensuring successful implementation of communication-and-resolution programmes.

Mello MM, Roche S, Greenberg Y, et al. BMJ Quality & Safety. 2020.

A smartphone app designed to empower patients to contribute toward safer surgical care: community-based evaluation using a participatory approach.

Russ S, Latif Z, Hazell AL, et al. JMIR mHealth and uHealth. 2019;8.

Overprescribing of opioids to adults by dentists in the U.S., 2011-2015.

Suda KJ, Zhou J, Rowan SA, et al. Am J Prev Med. 2020.

How does the WHO Surgical Safety Checklist fit with existing perioperative risk management strategies? An ethnographic study across surgical specialties.

Wæhle HV, Haugen AS, Wiig S, et al. BMC Health Services Research. 2020;20.

Commentary

Zero harm in health care.

Gandhi TK, Feeley D, Schummers D. NEJM Catalyst. 2020;1.

The benefits and burdens of working with patient safety organizations under the Patient Safety and Quality Improvement Act of 2005

Dwyer PE, Watts CD. J Health Life Sci Law. 2020;13.

Book/Report

Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey: 2020 User Database Report.

Famolaro T, Hare R, Thornton S, et al. Surveys on Patient Safety Culture^TM(SOPS^TM) Ambulatory Surgery Center Survey: 2020 User Database Report. Rockville, MD: Agency for Healthcare Research and Quality; Jan 2020. AHRQ Publication No. 20-0016.

Providing Safe, High-Quality Maternity Care in Rural US Hospitals. IHI Innovation Report.

Laderman M, Renton M. Providing Safe, High-Quality Maternity Care in Rural US Hospitals. IHI Innovation Report. Boston, MA: Institute for Healthcare Improvement; 2020.

Safety in Numbers: Hospital Performance on Leapfrog’s Surgical Volume Standard Based on Results of the 2019 Leapfrog Hospital Survey.

Safety in Numbers: Hospital Performance on Leapfrog’s Surgical Volume Standard Based on Results of the 2019 Leapfrog Hospital Survey. Washington DC; 2020.

Press Release/Announcement

ISMP Survey on the Two NEW 2020-2021 Targeted Medication Safety Best Practices for Hospitals

ISMP Survey on the Two NEW 2020-2021 Targeted Medication Safety Best Practices for Hospitals.

Newspaper/Magazine Article

The glaring loophole in U.S. virus response: human error.

Ehley B. The glaring loophole in U.S. virus response: human error. Politico. March 2, 2020.

I thought Daniel was safe with the NHS. He wasn't.

Calvert J, Arbuthnott G. I thought Daniel was safe with the NHS. He wasn't. The Sunday Times (UK). March 1, 2020.

Good medical care can suffer late in the day.

Gordon M. National Public Radio. 2020.

March 11, 2020

Periodic Issue

Email Updates

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Study

Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients

Wooldridge AR, Carayon P, Hoonakker P, et al. App Ergon. 2020;85.

Fernholm R, Holzmann MJ, Wachtler C, et al. BMC Fam Pract. 2020;21.

Association of work environment with missed and rushed care: tasks among care aides in nursing homes.

Song Y, Hoben M, Norton PG, et al. JAMA Network Open. 2020;3.

Adverse events present on arrival to the emergency department: the ED as a dual safety net.

Griffey RT, Schneider RM, Todorov AA. The Joint Commission Journal on Quality and Patient Safety. 2020.

Cracking the code for quality: the interrelationships of culture, nurse demographics, advocacy, and patient outcomes.

DiCuccio MH, Colbert AM, Triolo PK, et al. Cracking the code for quality: the interrelationships of culture, nurse demographics, advocacy, and patient outcomes. J Nurs Adm. Epub 2020 Feb 11. doi: 10.1097/nna.0000000000000859.

Prevalence, nature and predictors of omitted medication doses in mental health hospitals: a multi-centre study.

Keers RN, Hann M, Alshehri GH, et al. Prevalence, nature and predictors of omitted medication doses in mental health hospitals: a multi-centre study [Epub 2020 Feb 7]. PLoS One. 2020;15(2):e0228868. doi: 10.1371/journal.pone.0228868.

Patient perspectives on the usefulness of an artificial intelligence-assisted symptom checker: cross-sectional survey study.

Meyer AND, Giardina TD, Spitzmueller C, et al. Patient perspectives on the usefulness of an artificial intelligence-assisted symptom checker: cross-sectional survey study. J Med Internet Res. Epub 2020 Feb 6. 2020;22(1):e14679. doi: 10.2196/14679.

Review

Artificial intelligence and surgical decision-making.

Loftus TJ, Tighe PJ, Filiberto AC, et al. JAMA Surg. 2019;155:10.

Medical teamwork and the evolution of safety science: a critical review.

Neuhaus C, Lutnæs DE, Bergström J. Cogn Technol Work. 2020;22.

Interventions to reduce adverse drug event-related outcomes in older adults: a systematic review and meta-analysis.

Tecklenborg S, Byrne C, Cahir C, et al. Drugs & Aging. 2020;37.

Commentary

Data-driven quality improvement, culture change, and the high reliability journey at a special hospital for people with medically complex developmental disabilities.

Barba V, Foreman K, Robey K. Data-driven quality improvement, culture change, and the high reliability journey at a special hospital for people with medically complex developmental disabilities. Int J Healthc Manag. Epub 2020 Feb 6. doi: 10.1080/20479700.2020.1721747

Soft factors, smooth transport? The role of safety climate and team processes in reducing adverse events during intrahospital transport in intensive care.

Latzke M, Schiffinger M, Zellhofer D, et al. Soft factors, smooth transport? The role of safety climate and team processes in reducing adverse events during intrahospital transport in intensive care [Epub 2017 Nov 28]. Health Care Manage Rev. 2020;45(1):32-40. doi: 10.1097/hmr.0000000000000188.

Responding to unprofessional behavior by trainees - a "just culture" framework.

Wasserman JA, Redinger M, Gibb T. New England Journal of Medicine. 2020;382.

Web Resource

SOPS Medical Office Database.

SOPS Medical Office Database. Agency for Healthcare Research and Quality (AHRQ). March 2020.

Upcoming Meeting/Conference

Improving Safety Culture Using the AHRQ SOPS Nursing Home Survey.

Improving Safety Culture Using the AHRQ SOPS Nursing Home Survey. Agency for Healthcare Research and Quality. April 7, 2020; 12:00-1:00 PM (Eastern).

Leading Patient Safety: United Kingdom.

Institute for Healthcare Improvement. Leading Patient Safety: United Kingdom. March 31–April 2, 2020. CCT Venues-Barbican, London, UK.

Press Release/Announcement

A Decade of Patient Safety 2020-2030

A Decade of Patient Safety 2020-2030. Geneva, Switzerland; World Health Organization: February 2020.

Newsletter/Journal

Errors associated with oxytocin use: a multi-organization analysis by ISMP and ISMP Canada.

Errors associated with oxytocin use: a multi-organization analysis by ISMP and ISMP Canada. ISMP Medication Safety Alert! Acute care edition. February 13, 2020;25.

Newspaper/Magazine Article

A 25-year-old teacher died after waiting hours at the ER. She's not the only one who saw delays.

Linnane R, Diedrich J. A 25-year-old teacher died after waiting hours at the ER. She's not the only one who saw delays. Milwaukee Journal Sentinel. February 25, 2020.

At Walgreens, complaints of medication errors go missing.

Gabler E. At Walgreens, complaints of medication errors go missing. New York Times. February 23, 2020.

Book/Report

Shifting the Mindset: A Closer Look at Hospital Complaints.

Shifting the Mindset: A Closer Look at Hospital Complaints. Newcastle upon Tyne, UK: Healthwatch; January 2020.

Special or Theme Issue

Supplement on Deepening our Understanding of Quality in Australia (DUQuA).

Supplement on Deepening our Understanding of Quality in Australia (DUQuA). Int J Qual Health Care. 2020;32(Supp1):1-105.

WebM&M

March 25, 2020

Web M&M Edition March 2020

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WebM&M Cases

Some Patients Can’t Wait: Improving Timeliness of Emergency Department Care

Spotlight Case

CE/MOC

David Barnes, MD, FACEP and Rita Chang, MD,

March 2020

A 46-year-old woman presented to the emergency department (ED) triage with a history of a stroke, methamphetamine use, and remote endovascular repair of a thoracic aortic dissection. Her chief complaint was abdominal pain and vomiting and she was assigned Emergency Severity Index (ESI) category 2; however, there were no available beds, so the patient remained in the waiting room. Several hours later, she began to scream in pain on the waiting room floor, was quickly assessed as needing surgery; however, surgery was delayed, and the patient died in the ED.

Right Electrocardiogram, Wrong Patient

Christopher Chen, MD and Sandhya Venugopal, MD, MS-HPEd,

March 2020

The patient safety committee at a large tertiary care hospital received nine incident reports within three months involving electrocardiogram (EKG) reports that were uploaded into the wrong patients’ chart. All of these events were due to users failing to clear the previous patient’s information from, and/or users failing to enter the new patient’s information into, the EKG machine when obtaining an EKG.

Is that solution for IV or irrigation?: Fluid administration errors in the operating room.

Christian Bohringer, MD,

March 2020

Two patients admitted for deceased donor renal transplant surgery experienced similar near miss errors involving 1000 ml normal saline bags with 160mg gentamicin intended as bladder irrigation but mistakenly found spiked or next to the patient’s intravenous (IV) line. Confusion about using this nephrotoxic drug intravenously could result in significant harm to patients undergoing renal transplant surgery.