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December 18, 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

Vaghani V, Gupta A, Mir U, et al. JAMA Intern Med. 2024;Epub Dec 2.
Diagnostic errors continue to be a source of preventable harm. Researchers in this study developed and implemented electronic triggers (e-triggers) to identify missed opportunities for diagnosis (MOD) in Veterans Affairs emergency departments (ED) between 2016 and 2020. The e-triggers targeted six clinical scenarios: high-risk stroke, high-risk abdominal pain, unexpected ED or hospital return, concerning symptom-disease dyads (e.g., heart attack within 7 days of ED visit for chest pain), and lack of follow-up after abnormal test results. In a sample of 8.7 million treat-and-release ED visits, e-triggers showed modest positive predictive value (from 11.0% to 52.4%). The researchers found that most MODs (83%) involved process breakdowns during the clinician-patient encounter, such as failure to complete a physical examination or review previous documentation.
Wang J, Redelmeier DA. NEJM AI. 2024;1(12):AIcs2400639.
Previous studies have raised concerns about cognitive biases in healthcare recommendations provided by generative artificial intelligence (AI) models. In this study, researchers tested AI models using clinical vignettes involving 10 cognitive biases. Findings revealed significant discrepancies between AI and clinician recommendations, suggesting that AI models are prone to human-like biases in medical decision-making and that AI biases can be larger than those in practicing clinicians.
Zhang FH, Lauzon J, Payette J, et al. Br J Clin Pharmacol. 2024;90(11):2939-2946.
Effective communication is essential to reduce the risk of adverse drug events (ADEs) and other patient safety incidents during transitions of care from hospital to community settings. This article describes an iterative, consensus-based process to create a standardized medication discharge plan (MDP) for older adults and to identify essential principles to support MDP implementation, including patient prioritization, MDP format, and mode of transmission.
Wang J, Redelmeier DA. NEJM AI. 2024;1(12):AIcs2400639.
Previous studies have raised concerns about cognitive biases in healthcare recommendations provided by generative artificial intelligence (AI) models. In this study, researchers tested AI models using clinical vignettes involving 10 cognitive biases. Findings revealed significant discrepancies between AI and clinician recommendations, suggesting that AI models are prone to human-like biases in medical decision-making and that AI biases can be larger than those in practicing clinicians.
Vaghani V, Gupta A, Mir U, et al. JAMA Intern Med. 2024;Epub Dec 2.
Diagnostic errors continue to be a source of preventable harm. Researchers in this study developed and implemented electronic triggers (e-triggers) to identify missed opportunities for diagnosis (MOD) in Veterans Affairs emergency departments (ED) between 2016 and 2020. The e-triggers targeted six clinical scenarios: high-risk stroke, high-risk abdominal pain, unexpected ED or hospital return, concerning symptom-disease dyads (e.g., heart attack within 7 days of ED visit for chest pain), and lack of follow-up after abnormal test results. In a sample of 8.7 million treat-and-release ED visits, e-triggers showed modest positive predictive value (from 11.0% to 52.4%). The researchers found that most MODs (83%) involved process breakdowns during the clinician-patient encounter, such as failure to complete a physical examination or review previous documentation.
Knap LJ, Dijkstra-Eijkemans RI, Friele RD, et al. J Patient Saf. 2024;20(8):599-604.
Following serious adverse events, many affected patients and their families want to be involved in incident investigations. Dutch hospitals are required to involve them in investigations, and this study sought to understand how hospitals involve patients and their families and what drives their decisions to do so. Patients and families are invited to participate early in the investigation process, are involved throughout the investigation, and receive some kind of post-investigation report or summary. Hospitals must also balance the patient's need for information with hospital and physician interests.
Tabuchi H, Ishitobi N, Deguchi H, et al. BMJ Qual Saf. 2024;Epub Nov 29.
Wrong-side and wrong-patient surgical errors can have devastating consequences. In this study, an artificial intelligence (AI) error-detection program was implemented for all ophthalmic surgeries. The AI system was integrated with the WHO surgical safety checklist for patient identification, surgical laterality verification, and intraocular lens authentication. AI detected five errors (compared with one error pre-implementation), four of which occurred when the AI system was not fully implemented or properly used. In one case, the surgeon ignored both verbal warnings from a nurse and AI alerts. These results suggest that AI can be effective at identifying errors and preventing near misses but must be used in conjunction with existing safety practices that are fully adhered to.
Hartt CM, Weigand H, MacDonald AJ, et al. J Patient Saf Risk Manag. 2024;29(6):268-273.
Healthcare staff are frequently required to report errors and adverse events to their organization and regulatory bodies. In this study, community pharmacists in Canada share their experiences reporting to regulatory organizations through the Canadian Pharmacy Incident Reporting (CPhIR) database. The pharmacists were generally positive about reporting events but stated the requirement to report all events, including those that do not cause harm, such as name misspelling, is a burden on their already heavy workload. The authors suggest that a switch from a compliance-based culture to a just culture, where workers and organizations learn from their mistakes, may improve patient safety.
Zhang FH, Lauzon J, Payette J, et al. Br J Clin Pharmacol. 2024;90(11):2939-2946.
Effective communication is essential to reduce the risk of adverse drug events (ADEs) and other patient safety incidents during transitions of care from hospital to community settings. This article describes an iterative, consensus-based process to create a standardized medication discharge plan (MDP) for older adults and to identify essential principles to support MDP implementation, including patient prioritization, MDP format, and mode of transmission.
Lou SS, Lew D, Xia L, et al. JAMA Netw Open. 2024;7(12):e2447797.
Secure messaging (i.e., texts or instant messaging) is an increasingly common method of communication between clinicians. This study sought to explore the association between retract-and-reorder (RAR) events – a common proxy for wrong-patient prescribing events – and secure message volume for inpatient attending physicians, trainee physicians, and advanced practice practitioners. Clinicians with the highest secure messaging volume had higher odds of RAR compared to those with the lowest volume. Stratifying by clinician type, the association was observed only for attending physicians.
Minkoff H, O'Brien J, Berkowitz R. Obstet Gynecol. 2024;144(3):e50-e55.
Interventions to improve patient safety also contribute to physician burnout (e.g., decision support systems to reduce medication errors can result in alert fatigue and excessive time spent in the electronic health record). This commentary recommends several actions to reduce physician burnout while still maintaining patient safety: consider the impact of interventions on physician well-being, reduce the burden of documentation, offload some documentation to non-physicians/non-clinicians, coordinate training courses, rethink maintenance of certification, and take a multi-pronged approach that focuses on individual, departmental, institutional, and national concerns.
Maffeo M, Parente E, Ciofi D. J Pediatr Nurs. 2024;80:115-120.
Missed nursing care is the delay or omission of required nursing tasks, such as ambulation, turning, or feeding delays or omissions. In this review, common missed nursing care tasks in pediatrics included oral care, routine bathing, and adherence to infection protocols. Specific reasons for missed nursing care varied across studies but were generally associated with poor staffing levels and frequent interruptions.
Horck S. Leadership Health Serv. 2024;37(4):595-610.
Organizations are encouraged to learn from their failures but are not always able to do so. This review includes 49 studies that describe post-failure learning or non-learning behavior within healthcare organizations on four levels: individual, group, organizational, and global. Several factors susceptible to the impact of learning from failure (e.g., workload, communication) can be targeted in the design and development of new processes.
Schmidt HG, Norman GR, Mamede S, et al. J Eval Clin Pract. 2024;30(6):1091-1101.
Cognitive biases are consistently recognized as contributors to diagnostic error. This review identifies cognitive biases that are intrinsic (e.g., "difficult" patients) and extrinsic (e.g., availability bias) to the case and that result in misdiagnosis. Continued research to mitigate cognitive biases is required.
Vibe A, Rasmussen SH, Rasmussen NOP, et al. J Patient Saf. 2024;20(8):576-592.
Measuring and understanding patient safety culture (PSC) is essential for improving patient safety. This systematic review of 23 studies identified 81 predictors of PSC in hospital settings, but methodological differences in study design make it difficult to establish causality. The authors also note that most research on PSC focuses on an organizational/managerial approach.
No results.
National Action Alliance for Patient and Workforce Safety.
The AHRQ National Healthcare Safety Dashboard is one approach to tracking progress in the United States on patient and workforce safety using measures prioritized by national programs. The site provides centralized access to data from the AHRQ Patient Safety Indicators (PSIs), hospital Medicare adverse events, CMS hospital reporting programs, and hospital patient safety culture surveys.
Health Services Safety Investigations Body; October 2024.
The mental health patient safety domain is understudied. This series of reports, developed and distributed over the course of 2024 and 2025, covers a range of conditions that detract from safe delivery of mental health care in the United Kingdom. Topics will include the work environment and its contribution to patient safety incidents, as well as learning from adverse events.
Miller MA, Owens P, Kim J, et al. Agency for Healthcare Research and Quality; November 2024.
Methicillin-resistant Staphylococcus aureus (MRSA) is a constant threat to inpatient safety. This analysis from the AHRQ Healthcare Cost and Utilization Project examined data from 38 states reflecting the principle diagnoses, geographic distribution, and patient characteristics associated with the prevalence of MRSA infections across distinct patient populations.
Agency for Healthcare Research and Quality. Fed Register. December 12, 2024;89:100497-100498.
Underlying processes impact diagnostic effectiveness and safety. This call for public comment focuses on the value and usability of existing measures and others under development to track diagnostic excellence as an element of patient safety. Remarks on this notice must be received by February 13, 2025.
Tyler ER, Yalden O, Fan L, et al. Agency for Healthcare Research and Quality; November 2024. AHRQ Publication No. 25-0013
The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey on Patient Safety Culture ask health care providers and staff about the extent to which their organizational culture supports patient safety. The SOPS Workplace Safety Supplemental Item Set for Hospitals was designed for use in conjunction with the AHRQ Hospital Survey to help hospitals assess the extent to which their organization’s culture supports workplace safety for providers and staff. This 2024 data analysis from 94 participating hospitals found “Protection From Workplace Hazards” as the highest-scoring composite measure and “Addressing Workplace Aggression From Patients or Visitors” as the lowest-scoring composite measure. An average of 30% of healthcare providers and staff experienced symptoms of “Work Stress/Burnout,” which represents a 4-percentage point decrease from the 2022 study results.

This Month’s WebM&Ms

WebM&M Cases
Spotlight Case
Jonathan A. Edlow, MD, FACEP |
A patient in his mid-30s presented to the emergency department (ED) with three weeks of intermittent left-sided headaches, balance issues, and one brief episode of difficulty speaking and moving. On exam, the patient had normal vital signs, neurologic exam, and initial imaging; he was discharged from the ED without consultation from neurology. A few hours later, he suffered a stroke due to left posterior cerebral artery occlusion and vertebral artery dissection, leading to severe neurological deficits after delayed treatment. The commentary highlights the importance of thorough neurological investigation of patients presenting with dizziness and other simultaneous neurological symptoms, the challenges of diagnosing transient ischemic attack (TIA) – particularly in a young, healthy adult, and the limitations of non-contrast brain CT for identifying TIA or early ischemic strokes in patients presenting with dizziness. 
WebM&M Cases
Christian Bohringer, MBBS and Hong Liu, MD |
After drowning in a pool, a 19-month-old child arrived at the ED in respiratory distress, requiring intubation and mechanical ventilation. The patient’s SpO2 did not improve after the first intubation attempt; after a second attempt, it was discovered that the mechanical ventilator had not been connected to an oxygen source. The commentary discusses approaches to improving safety during emergency intubation, such as capnography confirmation, standardized algorithms to assess post-intubation hypoxia, and simulation training to improve intubation skills.
WebM&M Cases
Marla Shauer, PhD, CNM, MSN, Diana Guzman Perez, MS, Brenda Chagolla, RN, PhD, CNS, FACHE |
Infant feeding presents an opportunity for hospital and community staff to review safety processes around feeding of expressed breast milk or the provision of infant formula. This commentary describes safe infant feeding practices and strategies to avoid breast milk feeding errors or the provision of expired feeding products.

This Month’s Perspectives

Patricia Dykes headshot
Interview
Patricia Dykes, PhD, MA, RN, FAAN, FACMI, Zoe Sousane, BS, Sarah E. Mossburg, RN, PhD |
Dr. Patricia Dykes is the Program Director for Research at the Center for Patient Safety Research and Practice at Brigham and Women’s Hospital and a Professor of Medicine at Harvard Medical School. We spoke with her about falls and fall prevention.
Perspective
Patricia Dykes, PhD, MA, RN, FAAN, FACMI, Zoe Sousane, BS, Sarah E. Mossburg, RN, PhD |
This piece discusses the continuing challenge of preventing falls and explores strategies for preventing falls and falls with injury in both inpatient and outpatient settings.
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