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Content ArticleThis practice pointer in The BMJ explains why diagnostic errors occur and provides five strategies that healthcare workers can use to achieve diagnostic excellence. Each of these strategies is explored in detail: Seek diagnostic feedback, which includes tracking patient outcomes and seeking feedback from patients, families and other healthcare workers. "Byte sized" learning, which involves digital learning activities. Consider bias by getting to know patients and treating them as individuals, and through taking a 'diagnostic pause' to consider whether bias is playing into decisions. Make diagnosis a team sport through multidisciplinary huddles that include healthcare workers from different professions. Foster critical thinking by using intentional strategies to foster reflective scepticism and regular review.
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Content Article
Improving Diagnosis in Health Care (2015)
Patient-Safety-Learning posted an article in Diagnosis
Accurate and timely diagnosis is a key aspect of healthcare, and misdiagnosis and delayed diagnosis can have serious consequences for patients. This eBook published by the National Academies for Science, Engineering and Medicine highlights that tackling diagnostic error in healthcare is a moral, professional, and public health duty. It makes recommendations to improve the safety of diagnostic processes, outlining the need for collaboration and a widespread commitment to change among healthcare professionals, healthcare organisations, patients and their families, researchers and policy makers. -
Content ArticleAn expert committee will extend the vision for the nursing profession into 2030 and chart a path for the nursing profession to help create a culture of health, reduce health disparities, and improve the health and well-being of the US population in the 21st century. The committee will consider newly emerging evidence related to the COVID-19 global pandemic and include recommendations regarding the role of nurses in responding to the crisis created by a pandemic.
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Content Article"Shaming and punishing healthcare workers when an incident occurs sets a dangerous precedent for the industry. This will lead to a culture where healthcare workers avoid reporting near misses or errors for fear of repercussions, allowing process inefficiencies and systemic problems to occur." In this letter, Michael Ramsay, CEO of the Patient Safety Movement Foundation, highlights the negative ways in which criminalising healthcare workers who make mistakes will affect patient safety. He refers to the case of RaDonda Vaught, a nurse who was convicted of criminally negligent manslaughter in March 2022 for a medication error made while working at Vanderbilt University Medical Center in Nashville.
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Content ArticleThis study in The Joint Commission Journal on Quality and Patient Safety aimed to investigate factors affecting length of time to diagnosis in primary care in the USA. The authors found that patients presenting with new or unresolved problems in ambulatory primary care often remain undiagnosed after a year. There were no provider or patient-level variables associated with lack of diagnosis and further research is needed into the causes and consequences of lack of timely diagnosis.
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Content ArticleThis US study in BMJ Quality & Safety aimed to assess whether limiting the hours worked by first-year resident doctors' had an impact on patient safety. In 2011, The Accreditation Council for Graduate Medical Education (ACGME) enacted a policy that restricted first-year resident doctors in the USA to working no more than 16 consecutive hours. This policy was rescinded in 2017, and this study assessed the impact of the policy change by comparing the number of medical errors reported by first-year doctors in the five years before the ACGME was enacted (2002/2007) and in the three years following its implementation. The authors found that the 2011 work-hour policy was associated with a: 32% reduced risk of resident physician-reported significant medical errors 34% reduced risk of reported preventable adverse events 63% reduced risk of reported medical errors resulting in patient death They conclude that rescinding the policy in 2017 may be exposing patients to preventable harm.
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Content ArticleThis article in the journal IJQHC Communications examines how looking at the ‘Head’, ‘Heart’ and ‘Hands’ aspects of quality improvement can accelerate adoption of change, optimise the use of resources and maximise the impact and sustainability of interventions. It defines the different elements of Head, Heart and Hands approaches and looks at how these could be applied to rapidly changing environments such as healthcare systems during the Covid-19 pandemic.
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Content ArticleThe Dr. Lorna Breen Health Care Provider Protection Act in the USA aims to reduce and prevent suicide, burnout, and mental and behavioural health conditions among healthcare professionals. Healthcare professionals have long experienced high levels of stress and burnout, and COVID-19 has only exacerbated the problem. While helping their patients fight for their lives, many health care professionals are coping with their own trauma of losing patients and colleagues and fear for their own health and safety. This bill helps promote mental and behavioural health among those working on the frontlines of the pandemic. It also supports suicide and burnout prevention training in health professional training programs and increases awareness and education about suicide and mental health concerns among health care professionals.
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Content ArticleBoth the US Senate and the House of Representatives passed a bill to “improve the mental and behavioral health among health care providers” that President Biden signed on Friday. The Dr Lorna Breen Health Care Provider Protection Act is named after Lorna Breen, a New York City emergency medicine physician who died by suicide in April 2020, as Covid-19 raged across the city and the country. By all accounts a tireless worker, she was ultimately overwhelmed by what she experienced during those dark early days of the pandemic. Even before the coronavirus pandemic, health care institutions were struggling with maintaining the wellness of their workforces. Rates of burnout, depersonalisation, and emotional exhaustion were all significantly higher among healthcare workers than in the general population. Even more alarming, physicians and nurses complete acts of suicide at rates significantly higher than workers in other professions. The pandemic added fuel to this fire, as healthcare workers fought to provide care to legions of sick patients amid staffing and equipment shortages. Before the pandemic, approximately 40% of health care workers reported feeling burnt out. Now, between 60% and 75% of US healthcare workers report feeling emotionally drained and depressed. Clearly, something has to change. With the Breen bill, Congress hopes to halt this tragic wave of depression and burnout among health care workers by providing grants to hospitals and other health care organisations to “promote mental health and resiliency among health care providers.” Yet the solution the Breen bill proposes will not lead to meaningful change. Giving hospitals money to “promote wellness” will not magically heal healthcare workers. During the pandemic, hospitals across the country put up signs lauding their workers as heroes. Though hospital administrators may have given themselves pats on the back for such efforts, the signs meant little to those working without adequate personal protective equipment, or telling family members they could not visit dying loved ones, or wondering if they'd bring Covid home to their families and friends. The signs haven’t stopped scores of workers from leaving the healthcare field.
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Content ArticleAnalysis suggests potential instability and workforce gaps in the US healthcare sector. A call to action for all stakeholders could help. COVID-19 has altered many US nurses’ career plans. Over the past two years, McKinsey has found that nurses consistently, and increasingly, report planning to leave the workforce at higher rates compared with the past decade. Even as COVID-19 cases fluctuate, US healthcare providers are still experiencing the workforce and operational challenges exacerbated by the pandemic. Patient demand is expected to rise, given the growing and aging population of the United States. Without addressing this potentially wider divide between patient demand and the clinical workforce, with a specific focus on nurses, the US health sector could face substantial repercussions. If no actions are taken, there will likely be more patients in the United States who will need care than nurses available to deliver it. This report from McKinsey& Company provides context for how COVID-19 changed the nursing workforce, the long-term implications for nurses and healthcare stakeholders, and actions to consider to increase the odds of closing the gap. In the last section, it highlights how healthcare providers, federal and state governments, the private sector, the nursing workforce, and broader society could encourage those who are training to be nurses.
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Content ArticleIn 2010, the US Department of Health and Human Services Office of Inspector General (OIG) reported the first national incidence rate of patient harm events in hospitals—27% of hospitalised Medicare patients experienced harm in October 2008. During that month, hospital care associated with these events cost Medicare and patients an estimated $324 million in reimbursement, coinsurance, and deductible payments. Nearly half of these events were preventable. OIG conducted a new study to update the national incidence rate of patient harm events among hospitalised Medicare patients in October 2018. This work included calculating a new rate of preventable events and updating the cost of patient harm to the Medicare programme.
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Content ArticleAlthough compensation increases have played a key role in retaining and recruiting healthcare employees amid a major workforce shortage, perks such as mental health services and education financial assistance have also helped meet staff needs. Six health system CEOs and CFOs share with Becker's Hospital Review their best tips for retention and recruitment that go beyond compensation:
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Content Article
Who killed patient safety? (5 May 2022)
Patient Safety Learning posted an article in Research, data and insight
The medical communities commitment to patient safety has withered over the past 10-15 years after the original call for action in 2000 with the release of the IOM report. What was once a call for action, safety in hospitals and oversight by government has been deprioritised, defunded, and devalued, leaving patients like the authors of this article wondering: What happened to patient safety? -
Content ArticleThis article in the journal Implementation Science aims to offer a system for classifying implementation strategies. The article recommends that authors not only name and define their implementation strategies, but also specify who enacted the strategy, and the level and determinants that were targeted.
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Content ArticleProcesses relating to communication between healthcare professionals are complex and vulnerable to breakdown. In the electronic health record (EHR)-enabled healthcare environment, providers rely on technology to support and manage complex communication processes, and if implemented and used correctly, EHRs have potential to improve safety. This clinician communication self-assessment guide aims to help healthcare professionals determine how safe their practice is in relation to electronic health records (EHR) and communication.
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Content Article
AHRQ course- TeamSTEPPS® for diagnosis improvement
Patient-Safety-Learning posted an article in Diagnosis
Diagnostic harm is an area of concern in healthcare quality and patient safety. A growing body of patient safety and care delivery research shows that diagnostic harm is both widespread and costly. TeamSTEPPS is an evidence-based program built on a framework composed of four teachable, learnable skills—communication, leadership, situation monitoring and mutual support. The TeamSTEPPS for Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error. On the course. teams will learn about how improved communication among all members of the team can help lead to safer, more accurate and more timely diagnosis in all healthcare settings. The course can be delivered virtually, in a classroom setting or as individual self-paced learning modules. Additional resources for trainees include: Team assessment tool for improving diagnosis Case study of the diagnostic journey of Mr. Kane Reflective practice tool Postcourse knowledge assessment -
Content ArticleHypothermia is a common problem in the operating theatre, and it contributes to many poor outcomes including rising costs, increased complications and higher morbidity rates. This literature review in the Journal of PeriAnesthesia Nursing aimed to determine the best method and time to prewarm a patient in order to prevent hypothermia during or after surgery. The authors suggest that forced-air warming is most effective in preventing perioperative hypothermia. Eighty-one percent of the experimental studies reviewed found that there was a significantly higher temperature throughout surgery and in the post-operative care unit for patients who received forced-air prewarming.
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Content ArticleThis article looks at the benefits and process of prewarming patients before surgery, in order to maintain normothermia (a normal, safe temperature) throughout the peri-operative process. Increasing the patient's core temperature helps prevent hypothermia later on in surgery, reducing the need to deal with temperature issues during and after surgery. The author highlights the link between warming and patient safety and describes different approaches that can be taken for different lengths and types of surgical procedure.
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Content ArticleThis article describes perceptions of the culture of safety in paediatric primary care in the US, and evaluates whether organisational factors and staff roles are associated with these perceptions. The authors found that perceptions of the culture of safety and quality in paediatric primary care practices were generally positive, but differences in perceptions did exist based on staff role.
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Content ArticleAn estimated 1 in every 182 Americans will be diagnosed with cancer this year. Providing them safe care has inherent challenges, such as reaching an accurate diagnosis as quickly as possible, differentiating between disease progression and treatment side effects, and addressing broader systemic risks. Caitlyn Allen, sat down with medical oncologist and former chief quality officer of the Dana-Farber Cancer Institute, Dr. Joseph O. Jacobson, to discuss the evolution of oncology care and what the future may hold.
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Content ArticleThe opioid epidemic is a major public health concern in the US—according to the Center for Disease Control and Prevention (CDC), 70,630 people died from drug overdoses and 10.1 million people misused opioid prescriptions in 2019 alone. There are also an estimated 180,000 serious opioid-related adverse events in inpatient settings recorded annually. This blog by Dr Diane Perez, advisory board member at the Patient Safety Movement Foundation, looks at how patients and their families can get involved in solving the opioid epidemic. Opioids are potent pain relievers so it is critical that anyone that has a prescription be properly informed about the potential risks–both in and out of the hospital setting.
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Content ArticleThe US Institute for Safe Medication Practices (ISMP) list of error-prone abbreviations, symbols, and dose designations contains abbreviations, symbols, and dose designations which have been reported through the ISMP National Medication Errors Reporting Program (ISMP MERP) and have been misinterpreted and involved in harmful or potentially harmful medication errors. These abbreviations, symbols, and dose designations should NEVER be used when communicating medical information verbally, electronically, and/or in handwritten applications. This includes internal communications; verbal, handwritten, or electronic prescriptions; handwritten and computer-generated medication labels; drug storage bin labels; medication administration records; and screens associated with pharmacy and prescriber computer order entry systems, automated dispensing cabinets, smart infusion pumps, and other medication-related technologies.
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Content ArticleClosed-loop communication—when every test result is sent, received, acknowledged and acted upon without failure—is essential to reduce diagnostic error. This requires multiple parties within the healthcare system working together to refer, carry out tests, interpret the results and communicate them in language the patient can understand. If abnormal test results are not communicated in a timely manner, it can lead to patient harm. This Quick Safety case study looks at the case of a 47-year-old school teacher who had a screening mammogram. The radiologist identified a suspicious area of calcifications, which required follow up. The patient’s GP was not on the same electronic medical record (EMR) as the imaging centre and, because of front office changes, missed the notification to follow up. The patient was told that the radiologist would contact her if the results were abnormal and therefore assumed she was okay. A year later when seeing her GP, the patient was told that she needed follow-up testing and that she had stage 3 cancer. Her lesion had grown significantly, and she now required surgery, chemotherapy and radiation for advanced breast cancer. The case study suggests safety actions that should be considered to prevent this error from happening again.
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Content ArticleTeamSTEPPS (Team Strategies & Tools to Enhance Performance & Patient Safety) is an evidence-based set of teamwork tools created by the US Agency for Healthcare Research and Quality (AHRQ). It aims to optimise patient outcomes by improving communication and teamwork skills among healthcare professionals. An organisational readiness assessment, other guidance and all curriculum materials are available on this website.
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Content ArticleSpecialty referrals—when a clinician refers a patient to a specialist for evaluation or treatment—are on the rise in the US. Despite the introduction of electronic health records (EHRs), the referral process is often hindered by lack of clarity over roles, communication breakdowns, workloads and variations in requirements among specialists. These difficulties can lead to missed or delayed diagnoses, delays in treatment and other lapses in patient safety. This guide from the Institute for Healthcare Improvement offers recommendations that aim to help standardise how primary care practitioners activate referrals to specialists and then keep track of the information over time. It describes a nine-step, closed-loop process in which all relevant patient information is communicated to the correct person through the appropriate channels, in a timely manner.
