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February 5, 2020 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.

Matulis JC, Kok SN, Dankbar EC, et al. Diagnosis. 2020;7(2):107-114.
A brief survey of two internal medicine practices explored clinician perceptions of individual- and systems-level factors contributing to diagnostic errors. The most commonly reported individual-level factors contributing to diagnostic error was atypical patient presentations (83%), failure to consider other diagnoses (63%) and inadequate follow-up of test results (53%). Common systems-level contributors identified were cognitive burden associated with the electronic health record system (68%), inadequate time (64%) and lack of collaboration (40%).
Erickson SR, Kamdar N, Wu C-H. Am J Intellect Dev Disabil. 2019;125(1):37-48.
Prior research has found that children with intellectual or developmental disabilities (IDD) may experience poor quality care and are at risk for adverse events, but less is known about risk among adults with IDD. Using data from a nationally representative database, the authors compared hospitalizations due to adverse medication events among adults with IDD compared with the general adult population and found that adults with IDD were at a significantly greater risk of having a hospital admission due to an adverse event (odds ratio, 1.28).
Katz MG, Rockne WY, Braga R, et al. Am J Surg. 2020;219:21-26.
This study describes the impact of an upgraded patient safety reporting system that includes an option for positive reporting (e.g., teamwork, positive behavior) at a single academic medical center. The upgraded system resulted in a significant increase in the quantity and length of event reporting. The authors suggest that allowing for positive behavior reporting contributes to a culture of safety, which may have led to an increase in event reporting overall.
Sanghavi P, Pan S, Caudry D. Health Serv Res. 2020;55(2):201-210.
Nursing Home Compare publicly available reports on the quality and safety of care provided by nursing homes in the United States. Prior research has found that Nursing Home Compare does not accurately capture patient safety performance. This study compared falls with injury data self-reported by nursing homes against those identified in Medicare claims data and found that falls with injury were substantially underreported by nursing homes, indicating that that the data used by Nursing Home Compare may be inaccurate.
Stengel D, Mutze S, Güthoff C, et al. JAMA Surg. 2020.
The Joint Commission recognizes potential overuse of diagnostic imaging, particularly computed tomographic (CT) scans, to be a patient safety risk due to excess radiation exposure. This study sought to determine whether low-dose whole-body CT (WBCT), which exposes the patient to less radiation, has similar accuracy to standard-dose WBCT. A cohort of over 1,000 patients with suspected blunt trauma were prospectively recruited; half received standard-dose WBCT and the other half received low-dose WBCT.  The authors found that use of low-dose WBCT did not increase risk of missed injury diagnosis, while reducing median radiation exposure by almost half.
Garfield S, Furniss D, Husson F, et al. BMJ Qual Saf. 2020;29(9):764-773.
This mixed-methods study of patients, caregivers and healthcare professionals explores how patient-held medication lists (such as paper medication lists, medication diaries, or apps) can support patient safety. Patient-held lists can improve medication safety by improving the accuracy of medication reconciliation, identifying potential drug interactions, and facilitating communication.
Battar S, Dickerson KRW, Sedgwick C, et al. Fed Pract. 2019;36(12):564-568.
Polypharmacy is common among veterans. This articles describes the Veteran Health Administration’s implementation of an electronic, portable medication management tool to reduce polypharmacy by using the principles of high reliability organizations and combining best practice evidence, interprofessional teams, patient engagement, and integration of existing medical records systems. After three-years of implementation, an average of 2.15 medications were deprescribed per patient, with the most common being antihypertensives, over-the-counter medicines and antidiabetic medications.
Cooney L, Balcezak T. JAMA. 2020;323(2):179-180.
In an effort to identify cognitively impaired clinicians, this institution implemented a cognitive screening test for clinicians aged 70 years or older requesting reappointment to undergo a neuropsychological assessment. Eighteen clinicians (12.7% of those screened) exhibited cognitive deficits that could impair their capacity to practice medicine and who then voluntarily elected to retire or move into a closely proctored environment. Some had limitations in domains such as memory or executive function while others showed deficits in detail or visual analysis, information processing speed, or psychomotor efficiency.
Atkinson Smith M. Prof Case Manag. 2019;25(1):40-45.
Apology laws have been passed by numerous states and the District of Columbia, designed to make apologetic statements by clinicians inadmissible in court. This paper discusses disclosure training, stakeholder perspectives on error disclosure and apologies, and ethical and moral issues surrounding disclosure.
McHugh SK, Lawton R, O'Hara JK, et al. BMJ Qual Saf. 2020;29(8):672-683.
Team reflexivity represents the way individuals and team members collectively reflect on actions and behaviors, and the context in which these actions occur.  This systematic review identified 15 studies describing the use of team reflexivity within healthcare teams. Included interventions, most commonly simulation training  and video-reflexive ethnography, focused on the use of reflexivity to improve teamwork and communication. However, methodological limitations of included studies precluded the authors from drawing conclusions around the impact of team reflexivity alone on teamwork and communication.
Boggan JC, Shoup JP, Whited JD, et al. J Gen Intern Med. 2020;35(7):2136-2145.
Remote triage, which can be delivered via telephone, email or video conference, has been linked to potential adverse events. This systematic review evaluated the effects of remote triage systems on healthcare utilization and patient safety outcomes. Of the eight studies identified, three cluster RCTs found high rates of call resolution in local, practice-based triage services compared with regional or national services. Two cluster trials examined the effects of remote triage on mortality, hospitalizations and ED visits; neither reported statistically significant differences indicating increased risk for these patient safety outcomes.
Thibaut BI, Dewa LH, Ramtale SC, et al. BMJ Open. 2019;9(12):e030230.
This exploratory systematic review aimed to describe the state of the research on patient safety in inpatient mental health settings. Authors included 364 papers, representing 31 countries and data from over 150,000 participants. The existing research base was categorized into ten broad safety categories – interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorized leave, clinical decision making, falls, and infection prevention/control; papers were of varying quality with the majority of papers assessed as “fair”. The authors note that several areas of patient safety in inpatient mental health are particularly understudied, such as suicide, as the review only yielded one study meeting inclusion criteria.
The Institute for Professionalism and Ethical Practice. Fundamentals of Disclosure Coaching. Boston Children's Hospital, Harvard Medical School. March 27, 2020, 1:00-4:00 PM, Boston, MA.
Error disclosure skills are unique and rarely used, yet stressful, emergent situations often necessitate their use. This workshop shares strategies to develop coaches to rapidly aid clinicians involved in error. This strategy helps clinicians get the support they need to effectively apologize and discuss error with the patients, families and teams involved.
Aschwanden C. Wired Magazine. January 10, 2020.
The unintended consequences of artificial intelligence (AI) in healthcare continue to generate clinician concern. This magazine piece examines the potential diagnostic improvements to be realized from AI while cautioning about its premature use generating overdiagnosis and overtreatment.
Buissonniere M. Brooklyn NY: Lifebox and Ariadne Labs; 2020.
Checklists are integrated into error reduction strategies and healthcare team communication efforts worldwide but implementation and impact of the tool varies widely. This report examines the use of the WHO Surgical Safety Checklist and barriers to its uptake which include lack of effective staff introduction to the content, misperceptions about the time needed to use the tool and ineffective local contextualization of the content and process.
Partnership for HIT Patient Safety. Plymouth Meeting, PA: ECRI Institute; 2020.
Health information technology (HIT) can improve record keeping, test ordering and prescription legibility. This report highlights its value in assuring diagnostic communications are reliably completed and shares recommendations to support this work. The publication is accompanied by a guide for organizations to act on the recommendations for closed-loop communication.
Rockville, MD: Agency for Healthcare Research and Quality; December 2019. AHRQ Pub No 20-0023.
AHRQ has released the Network of Patient Safety Databases Chartbook, 2019 which offers an overview of nonidentifiable, aggregated patient safety event and near miss information, voluntarily reported by AHRQ listed Patient Safety Organizations from across the nation. The newly-released chartbook and accompanying dashboards (released in June 2019) outline the extent of harm reported, distribution of patient safety events, near misses (close calls), and unsafe conditions. Data within the chartbook cannot be used for statistical comparisons with clinical quality measures because the submission of data to the NPSD is completely voluntary.

Society to Improve Diagnosis in Medicine.

The impact of diagnostic error is increasingly clarified as research defines primary areas of concern. This grant program will provide 20 seed grants to multidisciplinary teams that include patients. The work will devise and test interventions to improve the diagnostic process. The 2022 application process closes March 25, 2022.
Feeley D, Torres T. Healthcare Executive. 2020;35(1):58-61.
A variety of biases can reduce the effectiveness and safety of care. This commentary focuses on racial bias and highlights its deleterious impact on maternity care and maternal safety. The authors suggest tactics to improve listening, implicit bias acknowledgement and data standardization as strategies to counteract the trend.
SB 1307, 117th Congress: 2021.
Reporting clinicians who exhibit practice behaviors that are detrimental to safety is challenged by system and cultural norms. This legislation aims to strengthen the US Veterans Health System process for identifying problematic clinicians by underscoring the importance of reporting to a national system that tracks these instances.

This Month’s WebM&Ms

WebM&M Cases
Spotlight Case
Monica Donnelley, PharmD, Thomas Joseph Gintjee, PharmD, and James Go, PharmD |
This commentary involves two patients who were discharged from the hospital to skilled nursing facilities on long-term antibiotics. In both cases, there were multiple errors in the follow up management of the antibiotics and associated laboratory tests. This case explores the errors and offers discussion regarding the integration of a specialized Outpatient Parenteral Antimicrobial Therapy (OPAT) team and others who can mitigate the risks and improve patient care.
WebM&M Cases
Garth H. Utter, MD, MSc and David T. Cooke, MD |
A man with mixed connective tissue disease on low-dose prednisone and methotrexate presented in very poor condition with chest and left shoulder pain, a left hydropneumothorax, and progressive respiratory failure. After several days of antibiotic therapy for a community-acquired pneumonia (CAP), it was discovered he had esophageal perforation.
WebM&M Cases
Nam K Tran, PhD, HCLD (ABB), FAACC and Ying Liu, MD |
This commentary involves two separate patients; one with a missing lab specimen and one with a mislabeled specimen. Both cases are representative of the challenges in obtaining and appropriately tracking lab specimens and the potential harms to patients. The commentary describes best practices in managing lab specimens.

This Month’s Perspectives

Annual Perspective
This perspective describes key themes reflected in AHRQ PSNet resources released in 2019 related to patient safety in primary care.
Annual Perspective
This perspective describes key themes reflected in AHRQ PSNet resources released in 2019 related to how the use of HIT can improve patient safety.
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