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December 18, 2019 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.

Gibson B, Butler J, Schnock KO, et al. Patient Educ Couns. 2019;103:741-747.
Patients and caregivers should be actively engaged in identifying and preventing patient safety events. This article describes the process of designing an app to engage patients and their caregivers in decision making that might impact safety.  The authors note important themes arising from this process, including appropriate messaging for patients, creating an app promotes actions (such as suggesting questions), and presenting information accessible for a lay audience.
Donnelly EA, Bradford P, Davis M, et al. CJEM. 2019;21:762-765.
While fatigue has been linked to safety-related outcomes in many healthcare settings, this link has not been definitively established in paramedicine. This article documents preliminary evidence—based on 717 surveys conducted in ten paramedic services in Ontario, Canada—of a relationship between fatigue and paramedic-reported safety outcomes and safety-compromising behaviors. The authors recommend fatigue mitigation efforts. 
Appelbaum N, Clarke J, Feather C, et al. BMJ Open. 2019;9:e032686.
While medication errors during paediatric resuscitation are considered common, little information about the processes that contribute to them has been gathered. This prospective observational study in a large English teaching hospital describes the incidence, nature and severity of medication errors made by 15 teams, each comprised of two doctors and two nurses, during simulated paediatric resuscitations. Clinically significant errors were made in 11 of the 15 cases, most due to discrepancies in drug ordering, preparation and administration. The authors recommend additional research into new approaches to protecting patients in paediatric emergency settings.
Martín Mª ÁP, García MM, Silveira ED, et al. Eur J Clin Pharmacol. 2019;75:1739-1746.
Trauma patients, who often suffer severe, multiple injuries and undergo multiple handoffs during long hospital stays, are particularly vulnerable to medication errors. This observational, descriptive, prospective study comprises an analysis of the medication errors that occurred during care transitions for all patients admitted to the trauma service unit of a hospital in Madrid, Spain over a four-month period. Results indicate that most medication errors occurred in the trauma unit and 64.2% of these types of errors were detected during the medication reconciliation process.
Sanduende-Otero Y, Villalón-Coca J, Romero-García E, et al. Br J Anaesth. 2020;124:197-205.
Medication-related adverse events (MRE) occur frequently during anesthesia care and more research into preventing them is needed. This article presents a descriptive analysis of the MRE reported to the Spanish Anaesthesia Incident Reporting System database during the decade from 2008 through 2017. Of the 1970 MRE identified, the highest number (42%) occurred during the administration phase, and a greater percentage of administration-related MRE resulted in harm to patients (44% as opposed to 31% over all 1,970 events). The authors identified patterns and specific causes of MRE that they suggest could be mitigated using proven systems solutions.
Huang C-H, Umegaki H, Watanabe Y, et al. PLOS ONE. 2019;14:e0211947.
Various tools for identifying potentially inappropriate medications (PIMs) have been developed. This 5-year prospective cohort study of 196 elderly patients receiving home-based medical services in Japan compared the use of two tools for identifying PIMs, the American Geriatrics Society’s Beers Criteria and the relatively new Screening Tool for Older Person’s Appropriate Prescriptions for Japanese (STOPP-J), to determine the impact of PIMs on hospitalization and mortality rates. PIMs categorized by STOPP-J were associated with hospitalization and mortality, whereas Beers Criteria PIMs were associated with hospitalization only after excluding proton pump inhibitors.
Kravet SJ, Bhatnagar M, Dwyer M, et al. J Patient Saf. 2019;15:e98-e101.
Few models for systematically targeting patient safety risks in large health systems exist. For this quality improvement study encompassing five large health care delivery systems, key informants were interviewed at seven affiliated outpatient sites in an effort to understand why ambulatory care accounted for 30-35% of annual medical malpractice costs and missed or delayed diagnoses comprised about 50% of liability risk associated with office practices. Analysis revealed eight common patient safety risk domains; the single most important was communication and follow-up of diagnostic test results. The authors recommend employing their targeted approach to safety improvements in other large health systems.   
Härkänen M, Vehviläinen‐Julkunen K, Murrells T, et al. J Nurs Scholarsh. 2019;52:113-123.
This retrospective study used descriptive statistics, manual analysis, and text mining of medication-related incident reports and staffing (N = 72,390) in England and Wales. The text mining was conducted with SAS Text Miner tool.  Effective trigger terms included “short staffing”, “workload”, and “extremely busy”.  The authors concluded that inadequate staffing, workload, and working in haste may increase the risk for errors.  The key importance of this article is the use of an automated system to analyze incident reports.
Levine KJ, Carmody M, Silk KJ. J Nurs Manag. 2019;28:130-138.
Medical errors occur frequently but there is great variability in whether they are reported. Focus groups and one-on-one interviews were used in this study to determine the effect of hospital culture and climate on employee decisions to speak up–or not–about medical errors. The authors conclude that their results, gathered from a large hospital in a mid-sized city in the midwestern U.S., indicate this hospital’s culture does not facilitate reporting of medical errors and suggest that creating a positive organizational culture can both promote speaking up about medical errors and increase patient safety.
Jones N. J Patient Saf. 2019;15:e36-e39.
This study surveyed surgical nurses at an Australian hospital regarding their perceptions of surgeon adherence to the World Health Organization surgical safety checklist. Though nurses felt surgeon-led time outs are valuable and lead to fewer adverse events, 94% of them reported experiencing hostility from surgeons, such as a "condescending, sarcastic attitude" related to the time out process.
Rozenblum R, Rodriguez-Monguio R, Volk LA, et al. Jt Comm J Qual Patient Saf. 2019;46:3-10.
Clinical decision support (CDS) tools help identify and reduce medication errors but are limited by the rules and types of errors programmed into their alerting logic and their high alerting rates and false positives, which can contribute to alert fatigue. This retrospective study evaluates the clinical validity and value of using a machine learning system (MedAware) for CDS as compared to an existing CDS system. Chart-reviewed MedAware alerts were accurate (92%) and clinically valid (79.7%). Overall, 68.2% of MedAware alerts would not have been generated by the CDS tool and estimated cost savings associated with the adverse events potentially prevented via MedAware alerts were substantial ($60/drug alert).
Millenson ML. Health Affairs Blog. December 2, 2019.
The two decades since To Err Is Human was published have raised and addressed a myriad of concerns affecting health care safety. This commentary examines the unintended consequences of the financial drivers to motivate improvement and the drive to define a business case for safety.

Frazer A, Rowland J, Mudge A, et al. Eur J Clin Pharmacol. 2019;75(12):1645-1657.

Adverse drug events associated with anticoagulation medications are common in hospitalized patients. This study comprises a systematic review and meta-analysis of 19 trials of controlled, system-level interventions (evaluating 12,742 patients) for improving the safety or quality of anticoagulant prescribing for hospitalized adults. Due to insufficient high-quality evidence, no reviewed intervention could be recommended, although some interventions merit further evaluation such as anticoagulation consultation services and decision supported warfarin dosing. The authors conclude that additional adequately powered, controlled trials—especially of interventions designed to ensure safe prescribing of low molecular weight heparins and direct acting oral anticoagulants—are needed.   
No results.

Garcia-Navarro L. Weekend Edition Sunday. National Public Radio. December 1, 2019.

Financial harms occur in health care due to a variety of factors such as overdiagnosis and ineffective billing practices. This radio interview highlights physician concerns over a hospital policy to sue patients and families for unpaid bills. Physicians at the organization have stated the practice works against their commitment to keeping patients from harm.
Arditi L. Peoples Public Radio. December 3, 2019.
Emergency medical services are often provided under chaotic circumstances that may contribute to failure. This story highlights a series of esophageal intubation errors and efforts to minimize this “never event” across the state of Rhode Island. Improvement strategies discussed include practice restrictions for EMT personnel and use of less invasive, less risky processes to provide oxygen as an alternative to intubation, which may reduce esophageal intubation errors
Newspaper/Magazine Article
Bendix J. Med Econ. November 25, 2019;96(23);10-14.
Implicit biases can compromise decision making due to the effect they can have on heuristics, communication and patient/physician communication. This article shares reasons for these biases and shares tactics to minimize their impacts which include being mindful of biases and a personalized approach to patients.
Tirrell M, Taylor H. CNBC. November 27, 2019.
Drug shortages are associated with increased medication errors and longer length of stays that increase risks to patients. This story examines how the issues affect cancer patients and suggests avenues for improvement.
Wears R, Sutcliffe K. New York, NY: Oxford University Press; 2019. ISBN: 9780190271268.
The modern patient safety movement has struggled to achieve the goals set forth in To Err Is Human. This book surveys the evolution of the collective error reduction effort in health care. The authors analyze the experience through social, legal, market, psychological and medical practice trends. They submit that the clinician-driven focus of improvement is reducing the momentum needed for lasting change. The publication provides recommendations to generate the improvement needed do minimize patient harm, notably the involvement of safety scientists.
Karlamangla S. Los Angeles Times. December 1, 2019.
Patient suicide is considered a sentinel event. This feature shares an examination of approximately 100 preventable deaths in the State of California over a decade. An examination of the case records identified breakdowns in care processes such as lack of training, low staffing and human error.
Lintern S. The Independent. November 18, 2019.
Infants are particularly vulnerable to patient safety errors. This article shares preliminary findings of a government investigation into infant deaths at a National Health Service Trust hospital. Initial insights discussed include the lack of a safety culture at the Trust Hospital facilitating the persistence of the problems.

This Month’s WebM&Ms

WebM&M Cases
Spotlight Case
Karl Steinberg, MD, CMD, HMDC and Thaddeus Mason Pope, JD, PhD |
A 63-year-old woman with hematemesis was admitted by a 2nd year medical resident for an endoscopy. The resident did not spend adequate time discussing her code status and subsequently, made a series of errors that failed to honor the patient’s preferences and could have resulted in an adverse outcome for this relatively healthy woman.
WebM&M Cases
Adrianne M Widaman, PhD, RD |
A 62-year-old man with a history of malnutrition-related encephalopathy was admitted for possible aspiration pneumonia complicated by empyema and coagulopathy. During the hospitalization, he was uncooperative and exhibited signs of delirium. For a variety of reasons, he spent two weeks in the hospital with minimal oral intake and without receiving most of his oral medications, putting him at risk for complications and adverse outcomes.
WebM&M Cases
Erika Cutler, PharmD, and Delani Gunawardena, MD |
A 55-year-old man visited his oncologist for a follow-up appointment after completing chemotherapy and reported feeling well with his abdominal and bony pain well controlled with opioid therapy.  At the end of the visit, his oncologist reordered his pain medication and, due to a best practice alert, also prescribed naloxone but failed to provide any instruction on its use. Later that day, the patient took the naloxone along with his opioid pain medication and within a minute experienced severe abdominal and bony pain, requiring admission to the emergency department.

This Month’s Perspectives

Cindy Brach
Interview
Cindy Brach, MPP is a Senior Healthcare Researcher at the Agency for Healthcare Research and Quality and is the Co-Chair of the HHS Health Literacy Workgroup. We spoke with her about the role of cultural competence in patient safety.  
Perspective
This piece describes cultural competence in the context of patient safety and highlights several approaches and projects that may help to improve cultural competence.
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