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March 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

Boyle FM, Horey D, Siassakos D, et al. BJOG. 2020;128(4):696-703.
Patients, parents and caregivers play an important role in improving patient safety. Although parents have expressed interest in engaging in perinatal mortality review processes, this international survey of healthcare providers found that less than one-third of respondents (from various types of healthcare facilities) included parents in the review process at their institutions. The authors discuss the potential importance of parental involvement after perinatal mortality to improve care.
Connolly W, Li B, Conroy RM, et al. J Patient Saf. 2020;17(2):141-148.
Since the release of To Err is Human, health systems have undertaken a multitude of patient safety initiatives to reduce adverse events. Findings from this systematic review demonstrate minimal reduction in overall risk of adverse event rates that can be attributed to implementation of large-scale patient safety initiatives (e.g. Global Trigger tool in inpatient and geriatric settings). The meta-analysis of included studies estimated one adverse event prevented for every 59 hospital admissions. The authors note a need for more research (particularly large-scale implementation studies) to establish the effectiveness of such initiatives.
Elbeddini A, Almasalkhi S, Prabaharan T, et al. J Pharm Policy Pract. 2021;14(1):10.
Medication reconciliation can improve patient safety, but prior research has documented challenges with implementation. Researchers conducted a gap analysis to inform the development of standardized medication reconciliation framework for use across multiple healthcare settings to reduce harm, including during the COVID-19 pandemic. Five key components were identified: (1) pharmacy-led medication reconciliation team, (2) patient education and involvement, (3) complete and accurate medication history, (4) admission and discharge reconciliation, and (5) interprofessional communication.
Elbeddini A, Almasalkhi S, Prabaharan T, et al. J Pharm Policy Pract. 2021;14(1):10.
Medication reconciliation can improve patient safety, but prior research has documented challenges with implementation. Researchers conducted a gap analysis to inform the development of standardized medication reconciliation framework for use across multiple healthcare settings to reduce harm, including during the COVID-19 pandemic. Five key components were identified: (1) pharmacy-led medication reconciliation team, (2) patient education and involvement, (3) complete and accurate medication history, (4) admission and discharge reconciliation, and (5) interprofessional communication.
Lloyd M, Watmough SD, O'Brien SV, et al. Res Social Adm Pharm. 2021;17(9):1579-1587.
Pharmacists play a critical role in reducing medication errors. This prospective study found that a formalized pharmacist-led prescribing feedback program can reduce prescribing errors. After program implementation, the overall prescribing error rate, as well as the frequency of each error type and severity, significantly decreased.
Cramer JD, Balakrishnan K, Roy S, et al. OTO Open. 2020;4(4):2473974X2097573.
Various surgical specialties have implemented surgical checklists to improve patient safety outcomes. In this survey of 543 otolaryngologists, surgical safety checklists were widely used, but intraoperative adverse events continue to occur. The most common adverse events reported were medication errors, wrong site/patient/procedure events, and retained surgical items.
Boussat B, Quan H, Labarere J, et al. Int J Qual Health Care. 2021;33(1).
Prior research has raised concerns about the accuracy of the patient safety indicators (PSIs). In an effort to improve accuracy, researchers combined PSI measurement with administrative data, manual review of a subsample of charts, and validity adjustment, and found that this approach can account for some validity concerns in estimating adverse event rates.
Boyle FM, Horey D, Siassakos D, et al. BJOG. 2020;128(4):696-703.
Patients, parents and caregivers play an important role in improving patient safety. Although parents have expressed interest in engaging in perinatal mortality review processes, this international survey of healthcare providers found that less than one-third of respondents (from various types of healthcare facilities) included parents in the review process at their institutions. The authors discuss the potential importance of parental involvement after perinatal mortality to improve care.
Jachan DE, Müller‐Werdan U, Lahmann NA. Nurs Open. 2021;8(2):755-765.
This survey of home care nurses in Germany identified several factors they perceived as contributing to medical errors, including workload and knowledge gaps. Findings indicate that regular error management trainings can improve hygiene and medication administration.
Ndabu T, Mulgund P, Sharman R, et al. JMIR Human Factors. 2021;8(1):e21884.
Health information technology (HIT) has had a profound impact on health care delivery and patient safety, but unintended consequences remain a concern. Findings from semi-structured interviews with medical and IT professionals indicate differing perspectives on the underlying causes of medical errors. While IT experts consider technology to be the source of most errors, clinicians attribute errors to person, process, and contextual factors. 
Richmond RT, McFadzean IJ, Vallabhaneni P. BMJ Open Qual. 2021;10(1):e001142.
Timely completion of discharge summaries can improve handoffs with outpatient physicians and ensure communication of potential patient safety problems. This quality improvement project used an established change model to improve the rate of discharge summary completed within 24 hours from less than 10%, to 84% within 2 months.
Giardina TD, Korukonda S, Shahid U, et al. BMJ Qual Saf. 2021;Epub Feb 19.
Patient complaints are increasingly used to identify opportunities for patient safety improvement and to predict avoidable patient harm. In this retrospective study, researchers analyzed patient complaint and medical record data and found that manual reviews by clinicians can identify patterns of failures in the diagnostic process. Qualitative analysis of complaints revealed three themes associated with diagnostic error – reports of return visits for the same or worsening symptoms, interpersonal issues, and diagnostic testing issues.
Tyler N, Wright N, Panagioti M, et al. Health Expect. 2021;24(Suppl 1):185-194.
Transitions of care represent a vulnerable time for patients. This survey found that safety in mental healthcare transitions (hospital to community) is perceived differently by patients, families, and healthcare professionals. While clinical indicators (e.g., suicide, self-harm, and risk of adverse drug events) are important, patients and families also highlighted the social elements of transitional safety (e.g., loneliness, emotional readiness for change).
English M, Ogola M, Aluvaala J, et al. Arch Dis Child. 2021;106(4):326-332.
Health systems are encouraged to proactively identify patient safety risks. In the first of a two-part series, the authors draw on the  Systems Engineering Initiative for Patient Safety (SEIPS) framework  to discuss the strengths and challenge of a low-resource newborn unit from a systems perspective and SEIPS’ implications for patient safety.
Vincent CA, Mboga M, Gathara D, et al. Arch Dis Child. 2021;106(4):333-337.
In the second of a two-part series, using examples from newborn units, the authors present a framework for supporting practitioners in low-resource settings to improve patient safety across four areas: (1) prioritizing critical processes, (2) improving the organization of care, (3) control of risks, and (4) enhancing responses to hazardous situations.
Olson APJ, Linzer M, Schiff GD. J Gen Intern Care. 2021;36(5):1404-1406.
Challenges to identifying and measuring diagnostic errors, particularly in the era of COVID-19, persist. The authors of this perspective proposed a new framework of diagnostic process safety to measure the quality and safety of diagnostic processes. The framework focuses on three measurable components – do not miss diagnoses, red flags, and diagnostic pitfalls. This framework can provide a structured approach for designing and testing specific measures of diagnostic process safety.
Takizawa PA, Honan L, Brissette D, et al. FASEB Bioadv. 2020;Epub Nov 17.
The COVID-19 pandemic has led to wide-ranging changes in the health care system. This article describes one academic hospital’s experience adapting in-person team-based clinical and interprofessional training during the COVID-19 pandemic.
Connolly W, Li B, Conroy RM, et al. J Patient Saf. 2020;17(2):141-148.
Since the release of To Err is Human, health systems have undertaken a multitude of patient safety initiatives to reduce adverse events. Findings from this systematic review demonstrate minimal reduction in overall risk of adverse event rates that can be attributed to implementation of large-scale patient safety initiatives (e.g. Global Trigger tool in inpatient and geriatric settings). The meta-analysis of included studies estimated one adverse event prevented for every 59 hospital admissions. The authors note a need for more research (particularly large-scale implementation studies) to establish the effectiveness of such initiatives.
No results.

Boodman SG. Washington Post. February 20, 2021.

Difficult diagnostic journeys are compounded by lack of clinician empathy, bias awareness, and critical thinking. This piece shares the story of a patient whose efforts to identify the cause of her pain were hampered by heuristics, premature closure, and poor patient relationship building.
Newspaper/Magazine Article

Armstrong D. Allen M. ProPublica. February 18, 2021.

The COVID-19 pandemic has revealed systemic weaknesses in health care access and delivery. This story examines how equipment shortages affected treatment decisions to culminate in rationing of needed therapies and contributed to patient deaths.

ISMP Medication Safety Alert! Acute care edition. February 11, 2021;26(3):1-4.

Packaging and labeling problems hinder safe medication use. This article discusses label appearance and information design as distinct factors that affect the safe use of premixed large volume intravenous solutions.

Babic B, Cohen IG,  Evgeniou T, et al. Harv Bus Rev.  2021 January/February;99(1):76-84.

 This article discusses how machine learning can create unanticipated risks in the context of health care delivery. The authors summarize areas of concern healthcare leadership should explore when determining the implementation of machine learning in their organizations.

This Month’s WebM&Ms

WebM&M Cases
Jennifer Branch, PharmD, Dakota Hiner, PharmD, and Victoria Jackson, MS, NP-C, PA-C |
A 93-year-old man on warfarin with chronic heart failure, atrial fibrillation, and a ventricular assist device (VAD) was admitted to the hospital upon referral from the VAD team due to an elevated internal normalized ratio (INR) of 13.4. During medication review, the hospital team found that his prescribed warfarin dose was 4 mg daily on Mondays and Fridays and 3 mg daily on all other days of the week; this prescription was filled with 1 mg tablets. However, his medication list also included an old prescription for 5 mg tablets. After discussions with the patient’s family, it was determined that the patient’s daughter had inadvertently given the patient three 5 mg tablets of warfarin (total daily dose 15 mg) for the past two days. This commentary discusses the importance of understanding patient safety risk, communication across transitions of care, and improving caregiver education and engagement to reduce medication errors.
WebM&M Cases
Wesley Valdes, DO and Garth Utter, MD, MSc |
A 71-year-old frail, non-ambulatory woman presented to the emergency department with fever, sweating and dry cough. Her work-up included non-specific evidence of infection but two negative COVID-19 tests. No source of infection was identified, and she was discharged home after three days. During a video visit with her primary care provider the next day, the patient noted worsening symptoms as well as a skin breakdown on her “backside”; however, no rectal or genital exams were completed during her inpatient stay and the physician did not visualize the area during the video visit. The patient was readmitted to the hospital two days later in septic shock due to a necrotizing soft tissue infection related to a perirectal abscess. The commentary discusses the need for a broad differential diagnosis in seriously ill patients, the influence of diagnostic biases during a pandemic, and how to address perceived limitations in the ability to examine patients in the setting of virtual care.
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.

This Month’s Perspectives

Libby Hoy
Interview
Libby Hoy, Patient Family Advisor (PFA), is the Founder and CEO of Patient Family Centered Care Partners (PFCCpartners). Stephen Hoy is the COO of PFCCpartners. We spoke to them about the current state of measurement of patient and family engagement and potential future directions.
Annual Perspective
In this PSNet Annual Perspective, we review key findings related to improvement strategies when communicating with patients and different structured communication techniques to improve communication across providers. Lessons learned from innovative approaches explored under COVID-19 that could be considered as usual care resumes are also discussed.
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