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January 13, 2021 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

Butler CR, Wong SPY, Wightman AG, et al. JAMA Netw Open. 2020;3(11):e2027315.
The COVID-19 pandemic has led to wide-ranging changes to health care delivery. This qualitative study with clinicians in the United States identified three emerging themes describing clinicians’ experience providing care in settings of resource limitations - planning for crisis capacity, adapting to resource limitations, and unprecedented barriers to care delivery. 
Friebe MP, LeGrand JR, Shepherd BE, et al. Appl Clin Inform. 2020;11(5):865-872.
The prescribing of potentially inappropriate medications, particularly among older adults, is an ongoing quality and safety concern. Among adults 65 years and older, this study found that clinical decision support integrated with a new electronic health record system significantly reduced potentially inappropriate medications.   
Chen A, Wolpaw BJ, Vande Vusse LK, et al. Acad Med. 2021;96(1):75-82.
Quality improvement and patient safety (QIPS) training is increasingly being incorporated into formal medical education. This article describes an integrated framework for QIPS training for internal medicine residents focused on four areas: (1) culture of safety, (2) strategies for investigating events and tracking improvements, (3) reporting and presenting events, and (4) improvement work. This specialty-agnostic framework allows for integration across graduate medical education (GME) specialties and can serve as a model for other institutions.  
Kobo-Greenhut A, Sharlin O, Adler Y, et al. Int J Qual Health Care. 2021;33(1):mzaa151.
Failure mode and effect analysis (FMEA) is used to asses risk in various heath care processes. This study found that an algorithmic prediction of failure modes in healthcare (APFMH) is more effective in identifying hazards and uses fewer resources (time and human resource investment) than traditional FMEA.
Trockel MT, Menon NK, Rowe SG, et al. JAMA Netw Open. 2020;3(12):e2028111.
Fatigue among health care workers can increase the risk of errors. This large cross-sectional study of attending and house staff physicians found that sleep-related impairment was associated with increased burnout, decreased professional fulfillment, and increased self-reported clinically significant medical error. Organizational policies should focus on reducing sleep-related impairment in order to reduce harm to patients and physicians.
Britton CR, Hayman G, Stroud N. J Perioper Pract. 2021;31(1-2):44-50.
The COVID-19 pandemic has highlighted the crucial role that team and human factors play in healthcare delivery. This article describes the impact of a human factors education and training program focused on non-technical skills and teamwork (the ONSeT project) – on operating room teams during the pandemic. Results indicate that the project improved team functioning and team leader responsiveness.
LeCraw FR, Stearns SC, McCoy MJ. J Patient Saf Risk Manag. 2021;26(1):34-40.
Healthcare systems have implemented communication-and-resolution programs (CRPs) to respond and disclose serious errors and adverse events. This article describes methods used by nine teams of CRP advocates to encourage adoption and endorsement by hospitals and national medical societies at the national, state, and local levels.  
Ricci-Cabello I, Gangannagaripalli J, Mounce LTA, et al. J Patient Saf. 2021;17(1):e20-e27.
Patient safety in primary care is an emerging focus. This cross-sectional study across primary care clinics in England explored the main factors contributing to patient-reported harm experiences. Factors included incidents related to communication, care coordination, and incorrect or delayed; diagnosis and/or treatment.
Dickens GL, Salamonson Y, Johnson A, et al. J Nurs Manag. 2021;29(4):690-698.
Prior research has identified gaps in nurses’ perceptions of safety in psychiatric inpatient units. Despite a need to improve service culture in an inpatient mental health service, this study found that a nurse leader and workplace culture program set in inpatient mental health wards in Australia resulted in small changes in safety culture.  
Spishock S, Meyers R, Robinson CA, et al. J Patient Saf. 2021;17(1):e10-e14.
Medication administration in pediatric patients can be complex and requires specialized dosing. In this observational study including over 15,000 medication orders, drug formulation manipulation was three times more common in pediatric versus adult inpatient practices. Manipulations most commonly involved oral liquids and intravenous orders and occurred most often in patients aged 1 to 12 months.
Friebe MP, LeGrand JR, Shepherd BE, et al. Appl Clin Inform. 2020;11(5):865-872.
The prescribing of potentially inappropriate medications, particularly among older adults, is an ongoing quality and safety concern. Among adults 65 years and older, this study found that clinical decision support integrated with a new electronic health record system significantly reduced potentially inappropriate medications.   
Peterson C, Moore M, Sarwani N, et al. Diagnosis (Berl). 2020;Epub Oct 29.
Recent duty hour reforms are intended to improve patient safety and resident well-being. This study explored whether resident performance declines as a function of consecutive overnight shifts, but results indicate no significant trend in overnight report discrepancies between the night float resident and the daytime attending.   
Lam BD, Bourgeois FC, Dong ZJ, et al. J Am Med Inform Assoc. 2021;28(4):685-694.
Providing patients access to their medical records can improve patient engagement and error identification. A survey of patients and families found that about half of adult patients and pediatric families who perceived a serious mistake in their ambulatory care notes reported it, but identified several barriers to reporting (e.g. no clear reporting mechanism, lack of perceived support).  
Butler CR, Wong SPY, Wightman AG, et al. JAMA Netw Open. 2020;3(11):e2027315.
The COVID-19 pandemic has led to wide-ranging changes to health care delivery. This qualitative study with clinicians in the United States identified three emerging themes describing clinicians’ experience providing care in settings of resource limitations - planning for crisis capacity, adapting to resource limitations, and unprecedented barriers to care delivery. 
Chin MH. BMJ Qual Saf. 2021;30(5):356-361.
Vulnerable populations are more likely to experience patient safety events. This editorial presents six recommendations for the patient safety field to support advances in health equity: (1) including health equity experts on interdisciplinary patient safety teams, (2) examining systems for bias, (3) considering the influence of social determinants of health on safety issues, (4) developing validated performance measures, (5) leveraging implementation science to scale-up and disseminate effective interventions, and (6) nurture moral incentives to improve equity in patient safety.  
Myers LC, Blumenthal KG, Phadke NA, et al. Jt Comm J Qual Patient Saf. 2021;47(1):54-59.
Learning from adverse events is a core component of patient safety improvement. These authors developed guidance for the use of peer review protected information (such as voluntary event reports and root causes analyses) in safety research. The guidance aims to ensure that data are handled safely and appropriately while supporting scientific discovery.  
Chen A, Wolpaw BJ, Vande Vusse LK, et al. Acad Med. 2021;96(1):75-82.
Quality improvement and patient safety (QIPS) training is increasingly being incorporated into formal medical education. This article describes an integrated framework for QIPS training for internal medicine residents focused on four areas: (1) culture of safety, (2) strategies for investigating events and tracking improvements, (3) reporting and presenting events, and (4) improvement work. This specialty-agnostic framework allows for integration across graduate medical education (GME) specialties and can serve as a model for other institutions.  

Coulthard P, Thomson P, Dave M, et al. Br Dent J. 2020;229:743-747; 801-805.  

The COVID-19 pandemic suspended routine dental care. This two-part series discusses the clinical challenges facing the provision of routine dental care during the pandemic (Part 1) and the medical, legal, and economic consequences of withholding or delaying dental care (Part 2).  
Purnell S, Zheng F. Surg Clin North Am. 2020;101(1):109-119.
COVID-19 restrictions and patient concerns have expanded access to telemedicine worldwide. This review examines the use of telemedicine in surgical services. The authors found it to be a safe care modality for low-risk patients receiving low-risk procedures. They found that telemedicine in surgical services evidence base is expanding and its value is built on local, real-time approaches that involve services designed to consider patient needs and comfort. 
No results.

Rockville, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Drug Evaluation and Research; December 7, 2020. 

Nonprescription drugs are commonly associated with medication errors. This draft guidance seeks to provide a structure for industry to reduce instances of drug name confusion in nonprescription formulas of prescription medications. It describes the US Food and Drug Administration (FDA) vetting process for drug names to improve naming actions prior to submission to the agency. The timeline for submitting comments is early February 2021. 

London UK: Crown Copyright; December 10, 2020. ISBN: 9781528623049.  

Maternal death and preventable poor neonatal outcomes are indications of health care safety and quality issues. This publication examined 250 instances of maternal and baby harm at a National Health Service trust between 2000 and 2019. Recommendations for improvement drawn from the analysis include the use of expert opinion, ward rounding, external incident review, team coordination, and organizational partnership activities focused on care delivery.
Special or Theme Issue

Zheng F ed. Surg Clin North Am. 2021;101(1):1-160.  

Surgical safety is a recognized area of emphasis in patient safety improvement. Articles in this special issue cover topics such as human factors, checklists, teamwork, and telemedicine as a safe support mechanism. 

Wright L. New Yorker. January 4, 2021;96(463):20-59. 

Uncertainty, misinformation, management gaps, and rapid escalation undermine crisis response effectiveness. This article illustrates system, leadership, and process failures that contributed to harms associated with the COVID-19 pandemic. 

This Month’s WebM&Ms

WebM&M Cases
Voltaire R Sinigayan, MD, FACP |
A 55-year-old man undergoing chemotherapy for acute myeloid leukemia was admitted to the hospital with a fever, neutropenia, and thrombocytopenia but physical examination did not reveal a focal site of infection. Blood and urine cultures were obtained, and he was started on IV antibiotics. His fever persisted and the cross-covering physician, following sign-out instructions from the primary team, requested repeat blood cultures but did not evaluate the patient in person. During rounds the next morning, the patient reported new oral pain (which had begun the previous day) and on physical exam was found to have mucositis. The associated commentary discusses the importance of in-person assessment in the hospital setting during cross-coverage and the value of structured, validated hand-off tools for communication among multidisciplinary teams.
WebM&M Cases
Christian Bohringer, MD |
A man with a history of previous airway operations was admitted for a rigid direct laryngoscopy. The consulting physician anesthesiologist prescribed a resident to administer ketamine to the patient as part of the general anesthesia protocol. The resident unintentionally located two vials of 100mg/mL ketamine (instead of the intended 10mg/mL vials that are used routinely) and erroneously administered 950mg of ketamine (instead of the intended 95mg). The dosing error resulted in delayed emergence from anesthesia and an unnecessary transfer to the intensive care unit for ventilation and monitoring, but was discharged home the following day. The commentary discusses the challenges of medication administration, the role of double-checking, and the importance of trainee supervision.
WebM&M Cases
Spotlight Case
Rebecca K. Krisman, MD, MPH and Hannah Spero, MSN, APRN, NP-C |
A 65-year-old man with metastatic cancer and past medical history of schizophrenia, developmental delay, and COPD was admitted to the hospital with a spinal fracture. He experienced postoperative complications and continued to require intermittent oxygen and BIPAP in the intensive care unit (ICU) to maintain oxygenation. Upon consultation with the palliative care team about goals of care, the patient with telephonic support of his long time caregiver, expressed his wish to go home and the palliative care team, discharge planner, and social services coordinated plans for transfer home. Although no timeline for the transfer had been established, the patient’s code status was changed to “Do Not Resuscitate” (DNR) with a plan for him to remain in the ICU for a few days to stabilize. Unfortunately, the patient was transferred out of the ICU after the palliative care team left for the weekend and his respiratory status deteriorated. The patient died in the hospital later that week; he was never able to go home as he had wished. The associated commentary describes how care inconsistent with patient goals and wishes is a form of preventable harm, discusses the need for clear communication between care team, and the importance of providers and healthcare team members serving as advocates for their vulnerable patients.

This Month’s Perspectives

Muhammad Walji
Interview
Elsabeth Kalenderian, DDS, MPH, PhD is a professor at UCSF. Muhammad F. Walji, PhD is the Associate Dean for Technology Services and Informatics and professor for Diagnostic and Biomedical Sciences at the UT Health Science Center at Houston, School of Dentistry. We spoke to them about the identification and prevention of adverse events in dentistry.   
Katie Suda
Interview
Katie J. Suda, PharmD, MS is a professor at the University of Pittsburgh School of Medicine in the Division of General Internal Medicine. She is a pharmacist by training with a specialty in infectious diseases and a research concentration in the area of dental antibiotic and opioid stewardship. We discussed antibiotic and opioid prescribing in dental care and challenges for implementing stewardship programs.
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