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Content ArticleThis study in the journal Current Problems in Diagnostic Radiology aimed to explore the perspectives of radiology and internal medicine residents on the desire for personal contact between radiologists and referring doctors, and the effect of improved contact on clinical practice. A radiology round was implemented, in which radiology residents travel to the internal medicine teaching service teams to discuss their inpatients and review ordered imaging. Surveys were given to both groups following nine months of implementation. The vast majority of both diagnostic radiology residents and internal medicine residents reported benefits in patient management from direct contact with the other group, leading the authors to conclude that this generation of doctors is already aware of the value of radiologists who play an active, in-person role in making clinical decisions.
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Content ArticleDefining whether a diagnostic error has occurred can be difficult, but in order to reduce harms from diagnostic errors, hospitalists must first understand how these errors occur and then develop practical strategies to avoid them. This article in the journal Annals of Internal Medicine explores these issues and highlights new opportunities for reducing diagnostic error in hospitals.
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Content Article
Medication safety in nursing home patients (5 July 2022)
Patient-Safety-Learning posted an article in Social care
Medication safety has long been a major issue in long-term social care due to the number of medications taken by many older people. This editorial in BMJ Quality & Safety looks at why managing medications in care homes is so complex and highlights potential interventions to improve medication safety in long-term care settings. -
Content ArticleEach year, up to 100 million people in the US experience acute or chronic pain, mainly because of short-term illnesses, injury and medical procedures. It is therefore important that patients are offered effective treatment options to reduce symptoms and improve function. Nonopioid management is the preferred option, but there are circumstances for which short-term opioid therapy is appropriate and beneficial. Finding the balance between these approaches is an ongoing problem in the management of acute noncancer pain. This cluster randomised clinical trial featured in JAMA Health Forum, aimed to assess whether clinician-targeted interventions prevent unsafe opioid prescribing in ambulatory patients with acute noncancer pain. The authors found that the use of comparison emails decreased the proportion of patients with acute pain who had never taken opioids receiving an opioid prescription. The emails also reduced the number of patients who progressed to treatment with long-term opioid therapy or were exposed to concurrent opioid and benzodiazepine therapy. They concluded that healthcare systems could add clinician-targeted nudges to other initiatives as an efficient, scalable approach to further decrease potentially unsafe opioid prescribing.
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Content ArticleConfusion between drug names that look and sound alike continues to occur and causes harm in all care settings, despite persistent prevention and mitigation efforts by industry, regulators, health systems, clinicians, patients and families. This editorial in BMJ Quality & Safety examines the results of a study that assessed the effect of mixed case (often referred to as ‘tall man’) text enhancement on critical care nurses’ ability to correctly identify a specific syringe from an array of similarly labelled syringes. The authors suggest further developments in this field of research and argue that a variety of different interventions will be needed to reduce medication errors caused by drug name confusion.
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Content ArticleIssues with medication management and errors in medication administration are major threats to patient safety. This article for the US Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network takes a look at the AHRQ's current areas of focus for medication safety. The authors look at evidence-based solutions to improve medication safety in three areas: High-risk medication use and polypharmacy in older adults Reducing opioid overprescribing, increasing naloxone access and use and other interventions for opioid medication safety Nursing-sensitive medication safety The article also explores future research directions in medication safety and highlights that these will advance patient safety overall.
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Content ArticleFifteen years after a “moral moment” transformed patient safety here, new systems and a change in culture at John Hopkins Medicine have gone a long way toward eradicating errors.
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Content ArticleOn 24 June 2022, the US Supreme Court overruled both Roe v. Wade and Planned Parenthood of Southeastern Pennsylvania v. Casey and returned the question of abortion’s legality to the US. The ruling opens the door to additional State efforts to limit access to medication abortions, prevent third parties from assisting anyone seeking an abortion or punish women who end their pregnancy. This opinion piece in The New England Journal of Medicine looks at the implications of the end of Roe v. Wade beyond abortion, examining how it could affect other aspects of healthcare rights in the USA. The author, Zita Lazzarini from the Division of Public Health Law and Bioethics at the University of Connecticut School of Medicine, argues that the Supreme Court's ruling opens the door for state regulation of other healthcare decisions, including those regarding contraception, end-of-life care, care for LGBTQ patients and fertility treatments. She highlights that common forms of birth control including IUDs and emergency contraception are already being targeted by some states as “abortifacients,” and raises concerns that State laws declaring that life begins at fertilization will potentially endow thousands of frozen embryos with rights, imposing impossible burdens on fertility centres and their clients.
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Content ArticleThe fishbone diagram is a widely-used patient safety tool that helps to facilitate root cause analysis discussions. The authors of this article in the journal Diagnosis expanded this tool to reflect how both systems errors and individual cognitive errors contribute to diagnostic errors. They describe how two medical centres in the US have applied this modified fishbone diagram to approach diagnostic errors in a way that better meets their patient safety and educational needs.
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Content ArticleIn order to become competent clinicians, doctors need to appropriately calibrate their clinical reasoning, but lack of follow-up after transitions of care can present a barrier to this. This study in the Journal of Hospital Medicine aimed to implement structured feedback about clinical reasoning for residents performing overnight admissions, measure the frequency of diagnostic changes, and determine how feedback impacts learners' self-efficacy. The authors concluded that structured feedback for overnight admissions is a promising approach to improve residents' diagnostic calibration, particularly given how often diagnostic changes occur.
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Content ArticleTo improve their diagnosis and management skills, doctors need consistent, timely and accurate feedback, as it helps them become better calibrated, leading to more appropriate clinical decisions. Despite its benefits, clinicians do not consistently receive information on the subsequent clinical outcomes of patients they have diagnosed and treated, known as patient outcome feedback. This paper discusses challenges faced in developing systems for effective patient outcome feedback. The authors propose applying a sociotechnical approach using health IT to support these systems. The concepts they discuss are applicable not only to fragmented systems of care, but also to integrated health systems that plan to harness the benefits of integration for providing effective clinician feedback.
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Content ArticleReducing errors in diagnosis is the next big challenge for patient safety. This article highlights ways in which healthcare organisations can pursue learning and exploration of diagnostic excellence (LEDE). Building on current evidence and their recent experiences in developing such a learning organisation at Geisinger in Pennsylvania, the authors propose a 5-point action plan and corresponding policy levers to support the development of LEDE organisations.
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Content ArticleThis study in JAMA Network Open aimed to investigate how often patients who read open ambulatory visit notes perceive mistakes, and what types of mistakes they report. The results of the study showed that: 1 in 5 patients who read a note reported finding a mistake 40% perceived the mistake as serious the most common mistakes reported were mistakes in diagnoses, medical history, medications, physical examination, test results, notes on the wrong patient and sidedness. The authors suggest that patients may perceive important errors in their visit notes, and inviting them to report mistakes may be associated with improved record accuracy and patient engagement in safety.
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Content Article
The Josie King Foundation
Patient Safety Learning posted an article in International patient safety
On 22 February 2001, eighteen-month-old Josie King died from medical errors. More than 250,000 people die every year from medical errors, making it the third leading cause of death in the United States. The Josie King Foundation’s mission is to prevent patients from dying or being harmed by medical errors. By uniting healthcare providers and consumers, and funding innovative safety programs, we hope to create a culture of patient safety, together. -
Content Article
The Betsy Lehman Center
Patient Safety Learning posted an article in International patient safety
The Betsy Lehman Center is a Massachusetts state agency that supports providers, patients and policymakers working together to advance the safety and quality of health care. -
Content ArticleNon-ventilator-associated hospital-acquired pneumonia (NVHAP) is one of the most common and deadly healthcare-associated infections, but it is not tracked, reported or actively prevented by most hospitals. This article in the journal Infection Control & Hospital Epidemiology highlights a national call to action to address NVHAP in the US. This national call to action includes: launching a national healthcare conversation about NVHAP prevention. adding NVHAP prevention measures to education for patients, healthcare professionals, and students. challenging healthcare systems and insurers to implement and support NVHAP prevention. encouraging researchers to develop new strategies for NVHAP surveillance and prevention.
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Content ArticleWhen hospital patients do not have their teeth brushed it can lead to them developing pneumonia—poor dental hygiene in hospital is believed to be a leading cause of hundreds of thousands of cases of pneumonia a year. In this blog for Medscape, reporter Brett Kelman looks at the link between dental hygiene and hospital-acquired pneumonia, which kills up to 30% of patients who are infected with it. He highlights a lack of understanding of the impact of failing to brush inpatients' teeth, in spite of a growing body of research evidence that links lack of adequate toothbrushing to pneumonia infection.
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Content ArticleIn this article, Maryanne Demasi looks at the continued prescription of Makena, an injectable synthetic hormone approved by the US Food and Drug Administration (FDA) to women who are at high-risk of premature delivery. Makena claims to reduce the risk of pre-term birth and was approved in 2011 on an accelerated pathway by the FDA following an initial trial that showed positive outcomes. However, Demasi explains, the study has been discredited as flawed in its methods and findings, and a confirmatory trial conducted by the manufacturer showed that Makena does not actually prevent preterm birth. In spite of this, and in the face of known risks, Makena is still being prescribed to pregnant women as the manufacturer has refused to withdraw it from the market. She highlights the dangers of the FDA not taking stronger action against the manufacturer of Makena, by looking at the example of Diethylstilbestrol (DES), a synthetic hormone use by women from the 1930's to the 1970s to prevent miscarriages and premature births. DES was later found to cause cancers, immune and cardiovascular disorders and other abnormalities in pregnant women, their children and their grandchildren.
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Content ArticleThis US study in the journal Medical Care aimed to assess the accuracy of Nursing Home Compare's (NHC) pressure ulcer measures, which are chief indicators of nursing home patient safety. The authors identified hospital admissions for pressure ulcers and linked these to nursing home-reported data at the patient level. They then calculated the percentages of pressure ulcers that were appropriately reported by stage, long-stay versus short-stay status, and race. Next, they estimated the correlation between an alternative claims-based measure of pressure ulcer events and NHC-reported ratings. The study found that pressure ulcers were substantially underreported in data used by NHC to measure patient safety. The authors call for alternative approaches to improve surveillance of health care quality in nursing homes.
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Soojin talks to us about how her personal experience of harm motivated her to work in healthcare and campaign for patient safety, the power of collaboration in improving healthcare safety and how healthcare workers can take steps to improve their own patient interactions. -
Content ArticleEarlier this year in March, a nurse from Vanderbilt University, RaDonda Vaught, was found guilty of criminally negligent homicide and gross neglect of a patient. In 2017, Vaught gave 75-year-old Charlene Murphey the incorrect medication. Murphey died as a result. Charlene Murphey’s tragic death highlights the failures of healthcare organisations and their leadership to be trustworthy as well as a fractured and weakened accountability system for patient safety in the United States.
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Content ArticleAn overview of the industry study by MxD and IAAE between February and June 2021 funded by FDA Office of Counterterrorism and Emerging Threats. The aim of the study was to gain an initial baseline to deepen FDA’s understanding of the factors that impact a manufacturer’s decision to invest in and adopt digital technologies by illuminating both perceived and demonstrated barriers from technical, business, and regulatory perspectives, and related cybersecurity considerations.
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Content ArticleThis article, published in Women Fitness Magazine, argues that a lack of awareness about safety measures and a shortage of healthcare professionals make it difficult for hospitals to ensure patient safety in the United States. It sets out six ways hospitals can ensure patient safety during treatment.
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Content ArticleAlcoholism, more professionally termed alcohol use disorder (AUD), is a widespread and costly behavioural health condition. The aims of this paper from Zipperer et al. are draw attention to systemic gaps in care for patients with AUD and advocate for patient safety leaders to partner with both the mainstream medical and substance abuse treatment communities to reduce harm in this patient population.
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Content ArticleThe US's response to monkeypox fails to put patients and their care at its centre, writes Eric Kutscher in the BMJ opinion article. As a primary care and addiction medicine physician, Kutscher has been dismayed by the number of patients he has treated over the past few weeks who’ve been infected with the vaccine-preventable monkeypox virus. Most have been in considerable pain and required strong analgesics, with some unable to even sit because of their skin lesions. Yet for many, the most agonising and scarring aspect of their infection is not their physical symptoms, but the complete removal of their humanity by the medical response to monkeypox. As a medical and public health community, we are exhausted after Covid-19, and our compassion fatigue is showing in our policies and procedures for monkeypox. The spread of the virus to previously non-endemic countries was only recently declared a public health emergency of international concern by the World Health Organization. Unlike with Covid-19, this is not a novel virus—we have the appropriate diagnostic testing, treatment, and even vaccines that we need. Yet, just as we have failed to deploy these tools to assist in outbreaks in African nations, we are now also failing our patients from a sexual minority—patients who are already underserved and justifiably mistrusting of a medical system.
