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February 3, 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

Haché M, Sun LS, Gadi G, et al. Paediatr Anaesth. 2020;30(12):1348-1354.
The Wake Up Safe initiative includes a registry of serious adverse events occurring in pediatric anesthesia. This study analyzed events reported between 2010 and 2015. The most common anesthesia-related events were medication events, respiratory complications, and cardiac events. Approximately 85% of these events were considered to be preventable.  
Janes G, Mills T, Budworth L, et al. J Patient Saf. 2021;17(3):207-216.
The delivery of safe, reliable, quality healthcare requires a culture of safety. This systematic review of 14 studies identified a significant relationship between healthcare staff engagement and safety culture, errors, and adverse events. The authors suggest that increasing staff engagement could be an effective way to enhance patient safety.  
Lewandowska K, Weisbrot M, Cieloszyk A, et al. Int J Environ Res Public Health. 2020;17(22):8409.
Alarm fatigue, which can lead to desensitization and threaten patient safety, is particularly concerning in intensive care settings. This systematic review concluded that alarm fatigue may have serious consequences for both patients and nursing staff. Included studies reported that nurses considered alarms to be burdensome, too frequent, interfering with patient care, and resulted in distrust in the alarm system. These findings point to the need for a strategy for alarm management and measuring alarm fatigue.  
Vinther S, Bøgevig S, Eriksen KR, et al. Basic Clin Pharmacol Toxicol. 2020;Epub Nov 6. .
Older adults living in long-term care facilities are at increased risk for medication errors. This cohort study examined nursing home residents exposed to medication errors and found that poison control consultations can assist nursing home staff in qualifying risk assessment and potentially reduce hospital admissions.
Hedsköld M, Sachs MA, Rosander T, et al. BMC Health Serv Res. 2021;21(1):48.
Intensive care units (ICUs) are complex environments that carry high risk for medical errors. This qualitative study characterized the role of front-line ICU managers in organizing for safe care and creating a culture of safety.  
Vimercati L, De Maria L, Quarato M, et al. Int J Infect Dis. 2021;102:532-537.
The pressures faced by hospitals and healthcare providers during the COVID-19 pandemic has raised concerns about nosocomial transmission of the virus. This single-setting study conducted in Italy including 5,750 healthcare workers compared the prevalence of COVID-19 infection among those in contact with COVID-19 patients and those working elsewhere in the hospital. The prevalence among exposed healthcare workers was 0.7% and 0.4% among all healthcare workers at this hospital. The authors conclude that correct use of personal protective equipment (PPE) and early identification of symptomatic healthcare workers can reduce nosocomial transmission.  
Bacon CT, McCoy TP, Henshaw DS. J Nurs Adm. 2021;51(1) :12-18.
Lack of communication and interpersonal dynamics can contribute to failure to rescue. This study surveyed 262 surgical staff about perceived safety climate, but the authors did not find an association between organizational safety culture and failure to rescue or inpatient mortality.  
Street RL, Petrocelli JV, Amroze A, et al. J Patient Exp. 2020;7(6):1247-1254.
Patient and family engagement play a critical role in patient safety. This study found that patient and family members perceived that information inadequacy, not listening, and dismissive behavior contributed to communication breakdowns that led to medical errors or close calls. These findings underline the critical role of patient and family engagement to prevent errors and improve care delivery.  
Ruutiainen HK, Kallio MM, Kuitunen SK. Eur J Hosp Pharm. 2021;Epub Jan 17.
Automated drug dispensing systems can reduce medication dispensing and administration errors.  However, this study found that medication automated dispensing cabinets ADCs)in one hospital frequently contained look-alike, sound-alike (LASA) medications, which may increase the risk for medication error.
Arshad SA, Ferguson DM, Garcia EI, et al. J Surg Res. 2021;257:455-461.
Engaging patients and families is an important strategy in ensuring safe health care delivery. In this prospective, observational study, use of a parent-centered script did not improve parent engagement during the preinduction checklist and resulted in an expected decline in checklist adherence.  
Erkelens DC, Rutten FH, Wouters LT, et al. J Patient Saf. 2020;Epub Dec 17.
Delays in diagnosis and treatment during after-hours care pose serious threats to patient safety. This case-control study compared missed acute coronary syndrome (ACS) cases to other cases with chest discomfort occurring during out-of-hours services in primary care. Predictors of missed ACS included the use of cardiovascular medication, non-retrosternal chest pain, and consultation of the supervising general practitioner.   
Haché M, Sun LS, Gadi G, et al. Paediatr Anaesth. 2020;30(12):1348-1354.
The Wake Up Safe initiative includes a registry of serious adverse events occurring in pediatric anesthesia. This study analyzed events reported between 2010 and 2015. The most common anesthesia-related events were medication events, respiratory complications, and cardiac events. Approximately 85% of these events were considered to be preventable.  
Connors CA, Dukhanin V, Norvell M, et al. J Healthc Manag. 2021;66(1):19-32.
The Resilience in Stressful Events (RISE) program provides peer support for healthcare workers who are involved in an adverse event. RISE program volunteers surveyed in this study reported positive perceptions of program participation and personal empowerment.  
Connolly W, Rafter N, Conroy RM, et al. BMJ Qual Saf. 2021;30(7):547-558.
This longitudinal study set in Ireland found that adverse event rates remained stable between 2009 and 2015. The authors found a decrease in the rate of preventable healthcare-acquired infections, and attributed these decreases to national programs and guidelines.  
No results.
Braun BI, Chitavi SO, Suzuki H, et al. Curr Infect Dis Rep. 2020;22(12):34.
A culture of safety is a key component to the success of a patient safety program. Despite limited empirical evidence, this review identified a positive relationship between safety culture, improvement in infection prevention and control-related processes, and decreases in healthcare-associated infections. 
Lewandowska K, Weisbrot M, Cieloszyk A, et al. Int J Environ Res Public Health. 2020;17(22):8409.
Alarm fatigue, which can lead to desensitization and threaten patient safety, is particularly concerning in intensive care settings. This systematic review concluded that alarm fatigue may have serious consequences for both patients and nursing staff. Included studies reported that nurses considered alarms to be burdensome, too frequent, interfering with patient care, and resulted in distrust in the alarm system. These findings point to the need for a strategy for alarm management and measuring alarm fatigue.  
Komashie A, Ward JR, Bashford T, et al. BMJ Open. 2021;11(1):e037667.
A systems approach is a key element in safe patient care. This systematic review concluded that a systems approach to healthcare design and delivery can lead to significant improvements in patient and service outcomes (e.g., fewer delays for appointments and time-to-treatment).  
Janes G, Mills T, Budworth L, et al. J Patient Saf. 2021;17(3):207-216.
The delivery of safe, reliable, quality healthcare requires a culture of safety. This systematic review of 14 studies identified a significant relationship between healthcare staff engagement and safety culture, errors, and adverse events. The authors suggest that increasing staff engagement could be an effective way to enhance patient safety.  

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 15, 2021. 

Vinca alkaloid misadministration is a persistent problem that results in patient harm and death. This alert raises awareness of label changes that aim to mitigate accidental spinal administration of the high-alert chemotherapy agent by supporting infusion bag administration only. 

Farnborough, UK: Healthcare Safety Investigation Branch; January 2021. 

 

Never events provide organizations with motivation to analyze and learn from errors due to their catastrophic nature. This National Learning Report provides a thematic examination of never events in the National Health Service (NHS). The report found misattribution of incidents as never events in the NHS due to lack of systemic factors as contributors to those events. A revision of the NHS never events list is recommended. 

Boodman SG. Washington Post. January 23, 2021.

Misdiagnosis can perpetuate over a long period and delay a correct course of treatment. This news feature shares an example of depression misdiagnosis that masked the true problem of a neurological tumor manifesting in what was seen and treated as a psychological condition. 
Multi-use Website

Sorry Works! 

Patients and families experiencing medical error may not always have access to the support needed to navigate the system to inform improvements and receive appropriate restitution. This hotline will provide general information to individuals that contact the organization for help when they feel an error may have occurred in their care or the care of a family member. 

This Month’s WebM&Ms

WebM&M Cases
Spotlight Case
David Barnes, MD and William Ken McCallum, MD |
A 56-year-old women with a history of persistent asthma presented to the emergency department (ED) with shortness of breath and chest tightness that was relieved with Albuterol. She was admitted to the hospital for acute asthma exacerbation. Given a recent history of mobility limitations and continued clinical decompensation, a computed tomography (CT) angiogram of the chest was obtained to rule out pulmonary embolism (PE).  The radiologist summarized his initial impression by telephone to the primary team but the critical finding (“profound evidence of right heart strain") was not conveyed to the primary team. The written radiology impression was not reviewed, nor did the care team independently review the CT images. The team considered her to be low-risk and initiated therapy with a direct oral anticoagulant (DOAC). Later that day, the patient became hemodynamically unstable and was transferred to the intensive care unit (ICU). She developed signs of stroke and required ongoing resuscitation overnight before being transitioned to comfort care and died. This commentary discusses the importance of avoiding anchoring bias, effective communication between care team members, and reviewing all available test results to avoid diagnostic errors.
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.
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