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January 27, 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

Abbas M, Robalo Nunes T, Martischang R, et al. Antimicrob Resist Infect Control. 2021;10(1):7.
The large burden placed on hospitals and healthcare providers during the COVID-19 pandemic has raised concerns about nosocomial transmission of the virus. This narrative review summarizes existing reports on nosocomial outbreaks of COVID-19 and the strategies health systems have implemented to control healthcare-associated outbreaks. The authors found little evidence describing the role of healthcare workers in reducing or amplifying infection transmission in healthcare settings.  
Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021;17(1):30-35.
Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.  

Toccafondi G, Di Marzo F, Sartelli M, et al. Int J Qual Health Care. 2021;33(Supp 1):51-55. 

 

The impact of the COVID-19 pandemic on infection prevention efforts and healthcare-associated infections is unclear. This article discusses how the COVID-19 pandemic has led to adaptations to infection prevention and control and surveillance (IPCS) practices and a human factors and ergonomics perspective in surgery. Leveraging lessons learned from the pandemic, the authors use a human factors perspective to propose an enhanced infection prevention and control approach to prevent surgical site infections. 
Dykes PC, Lowenthal G, Faris A, et al. J Patient Saf. 2021;17(1):56-62.
Failure to rescue – the lack of adequate response to patient deterioration – has been associated with adverse patient outcomes, particularly in acute care settings. This article describes two health systems’ efforts to implement in-hospital Clinical Monitoring System Technology (CMST) which positively impacted failure-to-rescue events. The authors identified barriers and facilitators to CMST use, which informed the development of an implementation toolkit addressing readiness, implementation, patient/family introduction, champions, and troubleshooting. 
Wessels R, McCorkle LM. J Healthc Risk Manag. 2021;40(4):30-37.
The COVID-19 pandemic has disrupted healthcare delivery. This study reviewed data from a large medical professional liability company to explore guidance sought by physicians and dentists during the initial months of the pandemic. Providers’ questions and concerns primarily involved operations (e.g., access to personal protective equipment, liability coverage), patient care (e.g., guidance for screening patients), scope of practice, and use of telemedicine.    
Menon NK, Shanafelt TD, Sinsky CA, et al. JAMA Netw Open. 2020;3(12):e2028780.
Burnout may adversely affect physician wellness and consequently patient safety. This cross-sectional study of 1,354 physicians found that depression was associated with suicidal ideation, while burnout was associated with self-reported medical errors.  

Kim T, Howe J, Franklin E, et al. Patient Safety. 2020;2(4):40–57.   

Patient misidentification errors have the potential for serious patient harm. This study analyzed the processes of care involved in 1,189 wrong-patient events. Most errors occurred during ordering/prescribing (42%). One-quarter of all events reached the patient, most commonly involving inappropriate medication administration or receiving the wrong test or procedure. Errors caught before reaching the patient were primarily attributed to information review by nurses, technicians, or other healthcare staff. The authors recommend several strategies for reducing wrong-patient errors. 
Tiao C-H, Tsai L-C, Chen L-C, et al. Qual Manag Health Care. 2021;30(1):61-68.
Hospitals have needed to adapt workflow processes to optimize infection control in response to the COVID-19 pandemic. This article describes the use of healthcare failure mode and effects analysis (HFMEA) 4-step model to implement preventive risk assessment and workflow management for high-risk medical procedures during the pandemic and prevention of nosocomial infections.   
Cutler NA, Halcomb E, Sim J, et al. J Clin Nurs. 2021;30(5-6):765-772.
Patient safety is an emerging focus within the mental health field. Using qualitative methods, the authors explored environmental influences on patient perceptions of safety in acute mental health settings. Participants highlighted the importance of staff presence, privacy, feeling safe from other patients, and access to meaningful activities (such as meaningful time alone or structured activities).  
Dye TD, Alcantara L, Siddiqi S, et al. BMJ Open. 2020;10(12):e046620.
Bullying and unprofessional behavior can negatively influence teamwork, staff retention, and patient safety. This cross-sectional study including over 7,000 adults from 173 countries found that healthcare workers were more likely to experience COVID-19-related harassment, stigma, and bullying in their home and workplace environments.  
Shaw J, Bastawrous M, Burns S, et al. J Patient Saf. 2021;17(1):30-35.
Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.  
Chen Y, Broman AT, Priest G, et al. Jt Comm J Qual Saf. 2021;47(3):165-175.
Fatigue among health care workers can increase risk of errors. This study posited that blue-enriched light could promote alertness and attention and thereby reduce medical errors in the ICU; however, the authors did not identify any effect of this intervention on error rates.  
Berg TA, Hebert SH, Chyka D, et al. Simul Healthc. 2020;Epub Dec 5.
Nurses are often responsible for medication administration at the bedside. This simulation study found that a smart phone app providing just-in-time medication administration information could reduce the occurrence of medication administration errors by nursing students. 
Abreu Saurin T. Safety Sci. 2027;134:105087.
The COVID-19 pandemic has raised new challenges and opportunities for quality improvement and safety science.The authors use a complexity thinking (understanding the dynamic interactions between systems) perspective to discuss the pandemic as a safety science problem with corresponding risk mitigation measures.
Rice JC, Daouk-Öyry L, Hitti E. BMJ Qual Saf. 2021;30(5):412-417.
Team training programs have become a core element of safety improvement strategies. Drawing upon lessons from aviation and cross-cultural psychology, the authors propose a proactive framework to promote cultural congruency in team training and the role of national culture trends affecting patient safety.  

Toccafondi G, Di Marzo F, Sartelli M, et al. Int J Qual Health Care. 2021;33(Supp 1):51-55. 

 

The impact of the COVID-19 pandemic on infection prevention efforts and healthcare-associated infections is unclear. This article discusses how the COVID-19 pandemic has led to adaptations to infection prevention and control and surveillance (IPCS) practices and a human factors and ergonomics perspective in surgery. Leveraging lessons learned from the pandemic, the authors use a human factors perspective to propose an enhanced infection prevention and control approach to prevent surgical site infections. 
Bhat A, Mahajan V, Wolfe N. J Clin Neurosci. 2021;85(Mar):27-35.
Misdiagnosis, variation in treatment of stroke and gaps in secondary prevention in young patients can result in adverse outcomes. This article discusses the possible causes of implicit bias in stroke care in this population, the effects of bias on patient outcomes, and interventions to circumvent implicit bias.  
Abbas M, Robalo Nunes T, Martischang R, et al. Antimicrob Resist Infect Control. 2021;10(1):7.
The large burden placed on hospitals and healthcare providers during the COVID-19 pandemic has raised concerns about nosocomial transmission of the virus. This narrative review summarizes existing reports on nosocomial outbreaks of COVID-19 and the strategies health systems have implemented to control healthcare-associated outbreaks. The authors found little evidence describing the role of healthcare workers in reducing or amplifying infection transmission in healthcare settings.  
No results.

Carayon P, Hignett S, Albolino S eds. Int J Qual Health Care. 2021;33(Supp1):1-71. 

 

Human factors approaches have been identified as one of the primary vehicles to create lasting patient safety innovation. Articles in this special supplement examine the role of human factors engineering and ergonomics in establishing improvement in organizational learning, pandemic response, and primary care management. 

ISMP Medication Safety Alert! Acute Care Edition. January 14, 2021;26(1);1-5. 
 

Learning from error rests on transparency efforts buttressed by frontline reports. This article examined reports of COVID-19 vaccine errors to highlight common risks that are likely to be present in a variety of settings and share recommendations to minimize their negative impact, including storage methods and vaccination staff education. 
Morton CH, Hall MF, Shaefer SJM, et al. J Obstet Gynecol Neonatal Nurs. 2021;50(1):88-101.
Individuals involved in adverse maternal events require support both physically and emotionally. This guidance combines readiness, recognition, response, and reporting and systems-learning steps to aid birthing facility nurses and management in providing standardized help for mothers, families, and care team members that experience care-related harm.  

Palo Alto CA; Gordon and Betty Moore Foundation: January 19, 2021. 

A lack of consensus on measures for the effectiveness and accuracy of diagnosis represents a gap in improvement methods. This announcement seeks proposals to examine quality measures to motivate excellence in three primary areas of diagnostic concern:  acute vascular events, infections, and cancer. The proposal submission process is now closed. 

Croskerry P. New York, NY: Oxford University Press; 2020. ISBN: 9780190088743. 

Diagnostic error reduction methods are evolving to enhance efforts supporting diagnostic improvements. This publication uses clinical cases to examine cognitive elements that contribute to problematic decision making. The model illustrates how bias and other reasoning flaws are more likely to result in diagnostic errors than a lack of knowledge would. 

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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