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January 20, 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

Han D, Khadka A, McConnell M, et al. JAMA Netw Open. 2020;3(12):e2024589.
Unexpected death or serious disability of a newborn is considered a never event. A cross-sectional analysis including over 5 million births between 2011 and 2017 in the United States found unexpected newborn death was associated with a significant increase in use of procedures to avert or mitigate fetal distress and newborn complications (e.g., cesarean delivery, antibiotic use for suspected sepsis). These findings could reflect increased caution among clinicals or indicate more proactive attempts to identify and address potential complications.  
Montgomery AP, Azuero A, Baernholdt MB, et al. J Healthc Qual. 2020;43(1):13-23.
Excess workload and burnout among nurses can compromise safe patient care and lead to adverse outcomes. This survey of acute care nurses in Alabama identified high levels of nurse burnout; burnout was a significant predictor of medication administration errors. All types of burnout – personal, work-related, and client-related – were significant predictors of self-reported medication administration errors.  
Yonash RA, Taylor M. Patient Safety. 2020;2(4):24-39.
Wrong-site surgeries can lead to serious patient harm and are considered never events by the National Quality Forum. Based on events reported to the Pennsylvania Patient Safety Reporting System between 2015 and 2019, the authors identified an average of 1.42 wrong-site surgery events per week and found that three-quarters of events resulted in temporary or permanent patient harm. The authors present several evidence-based strategies to reduce the likelihood of wrong-site surgery, including preoperative and intraoperative verification, site marking, and timeouts.  
Singh H, Carayon P. JAMA. 2020;324(24):2481-2482.
Preventable harm, such as diagnostic and medication errors, threaten patient safety in ambulatory care settings. This article discusses the scientific, practice, policy, and patient/family milestones necessary to accelerate progress in reducing preventable harm among outpatients and advance ambulatory safety. The authors recommend numerous key milestones, including improving measurement methods, routine monitoring of safety for improvement and learning, leveraging patient engagement, and a national patient safety center to coordinate and lead ambulatory safety efforts.   
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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.
Kjaergaard-Andersen G, Ibsgaard P, Paltved C, et al. Int J Qual Health Care. 2020;Epub Nov 10 .
Simulation training is used by hospitals to improve patient care. This study describes the experience of one Danish hospital shifting from simulation training at external centers to in situ training. The shift to in situ training identified several latent safety threats (e.g., equipment access, lack of closed-loop communication, out-of-date checklists) and these findings led to practice changes.  
Kozasa EH, Lacerda SS, Polissici MA, et al. Front Psych. 2020;11:570786.
Situational awareness during critical incidents is a key component of teamwork. This study found that a mutual care training can increase situational awareness for healthcare workers and consequently improve mental health and well-being before and during the COVID-19 pandemic.
Kannampallil T, Lew D, Pfeifer EE, et al. BMJ Qual Saf. 2020;Epub Dec 20.
Prior research has found that intraoperative anesthesia handovers can increase patient morbidity and mortality. However, this retrospective cohort study, focused on pediatric surgical patients treated, found that intraoperative anesthesia handovers were not associated with adverse postoperative outcomes.  
Han D, Khadka A, McConnell M, et al. JAMA Netw Open. 2020;3(12):e2024589.
Unexpected death or serious disability of a newborn is considered a never event. A cross-sectional analysis including over 5 million births between 2011 and 2017 in the United States found unexpected newborn death was associated with a significant increase in use of procedures to avert or mitigate fetal distress and newborn complications (e.g., cesarean delivery, antibiotic use for suspected sepsis). These findings could reflect increased caution among clinicals or indicate more proactive attempts to identify and address potential complications.  
Pryce A, Unwin M, Kinsman L, et al. Int Emerg Nurs. 2020;54:100956.
Emergency department (ED) overcrowding and prolonged ED stays can lead to adverse patient outcomes. This study examined patient flow bottlenecks in the ED and several factors posing risks to patient safety, such as prolonged time to triage and use of makeshift spaces (which may have inadequate staffing allocations or lack necessary equipment).
Montgomery AP, Azuero A, Baernholdt MB, et al. J Healthc Qual. 2020;43(1):13-23.
Excess workload and burnout among nurses can compromise safe patient care and lead to adverse outcomes. This survey of acute care nurses in Alabama identified high levels of nurse burnout; burnout was a significant predictor of medication administration errors. All types of burnout – personal, work-related, and client-related – were significant predictors of self-reported medication administration errors.  
Orth J, Li Y, Simning A, et al. Gerontologist. 2020;Epub Nov 19.
Nursing home patient safety culture is associated with healthcare quality and patient outcomes. This large cross-sectional study of nursing homes in the United States found that speaking-up behavior and communication openness were associated with a decreased risk of in-residence death among older adults with dementia. This association was strong in nursing homes located in states with higher nursing home nurse staffing requirements.  
Ebm C, Carfagna F, Edwards S, et al. J Crit Care. 2020;62:138-144.
Prescribing medications for indications that are not approved by the Food and Drug Administration (FDA) is common but poses a risk for medication errors. The authors of this study used simulation modeling to explore the influence of physician personal preference on off-label medication use during the COVID-19 pandemic.  
Rovers JJE, van de Linde LS, Kenters N, et al. Antimicrob Resist Infect Control. 2020;9(1):190.
Health systems are undertaking various approaches to reduce nosocomial transmission of COVID-19. This study found that psychiatric departments may be more susceptible to hospital-acquired COVID-19 due to treating high-risk populations, lower adherence to infection prevention policies, inadequate environmental changes, and organizational policy challenges.   
Yonash RA, Taylor M. Patient Safety. 2020;2(4):24-39.
Wrong-site surgeries can lead to serious patient harm and are considered never events by the National Quality Forum. Based on events reported to the Pennsylvania Patient Safety Reporting System between 2015 and 2019, the authors identified an average of 1.42 wrong-site surgery events per week and found that three-quarters of events resulted in temporary or permanent patient harm. The authors present several evidence-based strategies to reduce the likelihood of wrong-site surgery, including preoperative and intraoperative verification, site marking, and timeouts.  
Kandasamy S, Vanstone M, Colvin E, et al. J Eval Clin Pract. 2021; Epub Jan 6.
Physicians often experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. Based on in-depth interviews with emergency, internal, and family medicine physicians, this qualitative study explores how physicians experience and learn from preventable medical errors. In addition to exploring themes around the physician’s emotional growth and professional development, the authors discuss the value of sharing and learning from these experiences for colleagues and trainees.  
Singh H, Carayon P. JAMA. 2020;324(24):2481-2482.
Preventable harm, such as diagnostic and medication errors, threaten patient safety in ambulatory care settings. This article discusses the scientific, practice, policy, and patient/family milestones necessary to accelerate progress in reducing preventable harm among outpatients and advance ambulatory safety. The authors recommend numerous key milestones, including improving measurement methods, routine monitoring of safety for improvement and learning, leveraging patient engagement, and a national patient safety center to coordinate and lead ambulatory safety efforts.   
Hillman E, Paul J, Neustadt M, et al. Acad Med. 2020;95(12):1864-1873.
Quality improvement and patient safety (QIPS) programs are intended to increase patient safety competency during graduate medical education. This article describes the development and implementation of a consortium aimed to improve QIPS education at a large academic health center. Primary goals of the consortium include to (1) expand learner-driven, interprofessional opportunities, (2) leverage simulation training, and (3) engage and collaborate with community stakeholders.  
KM B. New York Univ Law Rev. 2020;95(5):1229-1318.
Maternal death or harm is disproportionately experienced by women of color in the United States. This perspective discusses legislative efforts to address discrepancies affecting the safety of this patient population. The author reviews weaknesses of this approach which include a lack of emphasis on state-level analysis of the problem to address system-level contributors to the problem.
Lee M, Lee N-J, Seo H-J, et al. West J Nurs Res. 2020;Epub Dec 24.
Patients and families are essential partners in identifying and preventing safety events. In this systematic review, the authors found that information-based interventions (e.g., videos, offline classes) promoting patient and family engagement in patient safety were mostly effective. The effectiveness of interventions involving both information and involvement (e.g., use of decision aids to determine care plan) strategies was inconsistent.  
No results.

Ofri D. New York Times. January 5, 2021. 

Physicians have unique perspectives when exposed to health care delivery problems as patients themselves or as caregivers. This news story shares the author’s frustrations with the system of care observed during an overnight visit at the bedside of her daughter awaiting an emergency appendectomy. Her experience underscored the value of patients and families engaging in the safety of actions clinicians take when providing care. 

Donaldson L, Ricciardi W, Sheridan S, Tartaglia R, eds. Springer Nature: Cham Switzerland; 2021. ISBN 9783030594022. 

 

Foundations and practical experiences are both necessary to implement and sustain change. This publication introduces core theories supporting patient safety improvement. It couples these concepts with discussions of how these can be applied in clinical areas to reduce factors that contribute to unsafe care. 

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.