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February 24, 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

Kaldjian LC. Patient Educ Couns. 2021;104(5):989-993.
Disclosure of and communication about errors and adverse events is increasingly encouraged in health care. This position paper discusses the key elements for effective communication about medical errors with patients and families and the importance of disclosure education in medical training, including the development of nonverbal skills.
Mulchan SS, Wakefield EO, Santos M. J Ped Psychol. 2021;46(2):138-143.
Implicit and explicit bias can reduce the effectiveness and safety of care. Based on a review of the literature, the authors conclude that the strain placed on provider resources, staff, and supplies by the COVID-19 pandemic may exacerbate implicit bias among pediatric providers. The authors discuss implicit bias at the individual, organizational, educational, and research levels, provide specific calls to action for pediatric healthcare providers, and discuss the role of pediatric psychologists in supporting other providers.
O’Connor P, O’malley R, Oglesby A-M, et al. Int J Health Care Qual. 2021;Epub Jan 19.
Patient safety problems can be challenging to detect. This systematic review identified a variety of methods for measuring and monitoring patient safety in prehospital care settings (e.g., emergency medical services, air medical transport). They include surveys, patient record reviews, incident reporting systems, interviews, and checklists.
Mahadevan K, Cowan E, Kalsi N, et al. Open Heart. 2020;7.
Distractions and interruptions are common during delivery of health care. In this evaluation of 194 cardiac catheterization procedures at a single hospital, the authors found that fewer than half of all procedures were completed without interruption or distraction. The authors propose several actions such as the use of a ‘sterile cockpit’ to reduce distractions and improve patient safety.
Dellinger JK, Pitzer S, Schaffler-Schaden D, et al. BMC Geriatr. 2020;20(1):506.
Polypharmacy in older adults is common and may increase risk of medication-related adverse events. This study found that an intervention combining educational training, tailored health information technology, and a therapy check process improved medication appropriateness in nursing home residents.  
Vsevolozhskaya OA, Manz KC, Zephyr PM, et al. BMC Health Serv Res. 2021;21(1):131.
Since 2014, Medicare’s Hospital-Acquired Condition Reduction Program (HACRP) reduces payments to hospitals with elevated rates of certain conditions. Based on multistate data, the authors conclude that there is a disconnect between penalties levied by the program and hospital performance, suggesting that the program may not drive patient safety improvements as intended.  
Greenberg N, Weston D, Hall C, et al. Occup Med (Lond). 2020;71(2):62-67.
The burden of the COVID-19 pandemic has placed healthcare workers at higher risk for poor mental health outcomes. This survey of doctors, nurses, and other healthcare staff working in intensive care units (ICUs) identified significant rates of probable mental health disorders and thoughts of self-harm. These findings reinforce the need to support the emotional well-being of healthcare workers during this crisis.
Sexton JB, Adair KC, Profit J, et al. Jt Comm J Qual Saf. 2021;47(5):306-312.
Healthcare workers may experience distress following adverse events. This survey of healthcare workers found that one-third had at least one colleague who experienced trauma after an adverse event. The authors also found that perceived institutional support was associated with a better safety culture and lower emotional exhaustion, highlighting the importance of support programs.
de Lemos J, Loewen PS, Nagle C, et al. BMJ Open Qual. 2021;10:e001161.
Adverse drug events – many of which are preventable – are a major source of patient harm. This cross-sectional study explored the causes of preventable adverse drug events (ADEs) and how patients, families, and providers can prevent them. The study finds that the most common causes of preventable ADEs involved providers not ensuring that patients and/or family understood the medication plan or could identify symptoms of side effects. The researchers used the study findings to develop learning messages for providers, patients, and families and to implement a preventable ADE surveillance system.
Zwaan L, El-Kareh R, Meyer AND, et al. J Gen Intern Med. 2021;Epub Feb 11.
Reducing harm related to diagnostic error remains a major focus within patient safety. Based on input from an international group of experts and stakeholders, the authors identified priority questions to advance diagnostic safety research. High-priority areas include strengthening teamwork factors (such as the role of nurses in diagnosis), addressing system factors, and strategies for engaging patients in the diagnostic process.
Kaldjian LC. Patient Educ Couns. 2021;104(5):989-993.
Disclosure of and communication about errors and adverse events is increasingly encouraged in health care. This position paper discusses the key elements for effective communication about medical errors with patients and families and the importance of disclosure education in medical training, including the development of nonverbal skills.
Blake JWC, Giuliano KK. AACN Adv Crit Care. 2020;31(4):357-363.
The COVID-19 pandemic has led to many changes in health care delivery. This article discusses one common process change – moving medical devices (such as intravenous (IV) infusion pumps) away from the bedside – and how to support nursing clinical decision-making during IV infusion therapy.  
Pan D, Rajwani K. Simul Healthc. 2020;16(1):46-51.
Simulation training is employed by hospitals to improve patient care. This article describes one hospital’s experience implementing simulation training during the COVID-19 pandemic to help refine protocols, facilitate practice changes, uncover safety gaps, and train redeployed healthcare workers.
van de Ruit C, Bosk CL. Work Occupat. 2020;48(1):3-39.
Based on interviews with patient safety officers and other healthcare workers in the United States, this article describes the evolving role of the patient safety officer in surgery departments and their role in driving behavior change, supporting safety culture, and improving patient outcomes.
Mulchan SS, Wakefield EO, Santos M. J Ped Psychol. 2021;46(2):138-143.
Implicit and explicit bias can reduce the effectiveness and safety of care. Based on a review of the literature, the authors conclude that the strain placed on provider resources, staff, and supplies by the COVID-19 pandemic may exacerbate implicit bias among pediatric providers. The authors discuss implicit bias at the individual, organizational, educational, and research levels, provide specific calls to action for pediatric healthcare providers, and discuss the role of pediatric psychologists in supporting other providers.
O’Connor P, O’malley R, Oglesby A-M, et al. Int J Health Care Qual. 2021;Epub Jan 19.
Patient safety problems can be challenging to detect. This systematic review identified a variety of methods for measuring and monitoring patient safety in prehospital care settings (e.g., emergency medical services, air medical transport). They include surveys, patient record reviews, incident reporting systems, interviews, and checklists.
Hicks S, Stavropoulou C. J Patient Saf. 2020;Epub Jan 5.
Disruptive and unprofessional behaviors can create unsafe environments for patients. Findings from 25 studies included in this systematic review conclude that disruptive behaviors among health care professionals consistently contribute to a reduction in the quality and safety of patient care. Disruptive behaviors led to adverse events and neglect of care, and significantly impaired safety culture.  
No results.
Newspaper/Magazine Article

Bookwalter CM. US Pharmacist. 2021;46(2):25-28. 

 

COVID-19 has increased uncertainties in sectors across health care. This article discusses a variety of supply-chain factors that impact medication availability. The author suggests roles for pharmacists in antibiotic stewardship and policy implementation to manage shortages safely.
Multi-use Website

United Kingdom.

Patients and families that experience medical harm have unique support needs. This organization works to improve health system and clinician response to harmed patients. Their efforts aim to create a deeper understanding of the factors contributing to lack of response to concerns to enhance existing processes.

Rockville, MD: Agency for Healthcare Research and Quality. February 9, 2021. PA-21-164.

 

Digital strategies hold promise for improving point-of-care efficiency, communication, and safety. This funding opportunity will support research exploring how digital technology can be designed and implemented to improve the quality of healthcare services delivery at the point of care. Areas of interest include the use of patient-facing technologies, development of advanced analytics, and improvements in point-of-care clinical decision making.

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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