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March 17, 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

Buetti N, Ruckly S, de Montmollin E, et al. Intensive Care Med. 2021;47(2):180-187.
The COVID-19 pandemic has led to changes in infection prevention and control practices and increased the risk for some healthcare-acquired infections. In this prospective matched case-cohort study, researchers found that after 7 days in the intensive care unit (ICU), the risk of ICU-acquired blood stream infections was higher among patients with COVID-19 compared to other critically ill patients.
Dryver E, Lundager Forberg J, Hård af Segerstad C, et al. BMJ Qual Saf. 2021;Epub Feb 19.
Checklists are commonly used in surgical and critical care settings to improve patient safety. This multisite study simulation study found that checklists can improve local resuscitation teams’ management of medical crises such as anaphylactic shock and septic shock in emergency departments.
Gregory ME, Hughes AM, Benishek LE, et al. J Patient Saf. 2021;17(2):e47-e70.
High reliability remains an elusive goal for health care organizations. The authors of this study posit that medical teams’ ABCs – attitudes, behaviors, and cognitions – are critical for high-reliability, enhancing team adaptation and increasing patient safety. The article outlines practical tools and educational strategies that can be leveraged by a variety of healthcare organizations to improve team-based care.
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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.
Catalanotti JS, O’Connor AB, Kisielewski M, et al. J Gen Intern Med. 2021;Epub Jan 30.
Overnight coverage creates opportunities for increasing resident autonomy but can carry risks for patient safety.  This study found that the presence of overnight hospitalists was associated with fewer resident barriers to contacting supervising physicians overnight but that other barriers during overnight coverage – such as technological barriers and organizational culture – influence residents seeking help from supervising physicians.
Buetti N, Ruckly S, de Montmollin E, et al. Intensive Care Med. 2021;47(2):180-187.
The COVID-19 pandemic has led to changes in infection prevention and control practices and increased the risk for some healthcare-acquired infections. In this prospective matched case-cohort study, researchers found that after 7 days in the intensive care unit (ICU), the risk of ICU-acquired blood stream infections was higher among patients with COVID-19 compared to other critically ill patients.

Ipsaro AJ, Patel SJ, Warner DC, et al. Hosp Pediatr. 2021;Epub Mar 3.

Understanding physician communication regarding diagnostic uncertainty is an important component of reducing diagnostic error. This article outlines a process for identifying pediatric inpatients with uncertain diagnoses and improving shared recognition among interdisciplinary health care teams.
Gurwitz JH, Kapoor A, Garber L, et al. JAMA Intern Med. 2021;181(5):610-618.
High-risk medications have the potential to cause serious patient harm if not administered correctly. In this randomized trial, a pharmacist-directed intervention (including in-home assessment by a clinical pharmacist, communication with the primary care team, and telephone follow-up) did not result in a lower rate of adverse drug events or medication errors involving high-risk drug classes during the posthospitalization period.
Mitchell G, Porter S, Manias E. J Adv Nurs. 2021;77(2):899-909.
Oral chemotherapy regimens are complex and may lead to severe adverse drug events. Through ethnographic research, the authors found that the two most important factors in ensuring optimal management of oral chemotherapy are (1) early recognition and appropriate response to side effects and (2) maintenance of safe and effective medication communication.
Dryver E, Lundager Forberg J, Hård af Segerstad C, et al. BMJ Qual Saf. 2021;Epub Feb 19.
Checklists are commonly used in surgical and critical care settings to improve patient safety. This multisite study simulation study found that checklists can improve local resuscitation teams’ management of medical crises such as anaphylactic shock and septic shock in emergency departments.
Groves PS, Bunch JL, Cannava KE, et al. Nurs Res. 2021;70(2):106-113.
A critical component of strong safety culture is that patients and families feel empowered to speak up about safety concerns. This qualitative study explored bedside nurses' experience responding to safety concerns expressed by patients or their families. Safety interventions designed to be used by nurses should be developed with nurses’ routine safety work in mind, be sensitive to the vulnerability of patients, and respect patient and family input.
Sreeramoju P, Voy-Hatter K, White C, et al. BMJ Open Qual. 2021;10(1):e001189.
Healthcare-associated infections (HAIs) and community-acquired sepsis can result in significant patient harm. This article describes one large academic hospital’s experience implementing a hospital-wide initiate to reduce HAIs and improve sepsis care.  Key components of the initiative included an awareness campaign and clinician engagement, implementation of HAI and sepsis bundles, electronic health record-based clinical decision support, and education and training. Over a five-year period, the initiative lowered HAI rates, reduced sepsis mortality, and improved safety culture.
Co Z, Holmgren AJ, Classen DC, et al. Appl Clin Inform. 2021;12(01):153-163.
Medication errors occur frequently in ambulatory care settings. This article describes the development and testing of an ambulatory medication safety evaluation tool, which is based on an inpatient version administered by The Leapfrog Group. Pilot testing at seven clinics around the US indicates that clinics struggled in areas of advanced decision support such as drug age and drug monitoring, and that most clinics lacked EHR-based medication reconciliation functions.
Paradis KC, Naheedy KW, Matuszak MM, et al. Pract Radiat Oncol. 2020;11(1):e106-e113.
Assessing risk and learning from adverse events are core components of patient safety improvement. The authors propose a method which leverages a radiation oncology incident learning system with a simplified failure mode and effects analysis (FMEA) to analyze safety events and monitor the success of workflow changes to improve patient safety and address high-risk errors.
Emonds EE, Pietruszka BL, Hawley CE, et al. J Am Pharm Assoc (2003). 2021;Epub Feb 9.
The “Hospital at Home’ program provides inpatient medical treatment (such as intravenous medications, daily laboratory monitoring, and basic imaging) to patients in their home under close clinician supervision. The authors found that integration of a pharmacist into the program enabled detection and resolution of medication discrepancies, which contributed to cost savings from medication dispensing and avoided early hospital discharge.
Panda N, Etheridge JC, Singh T, et al. World J Surg. 2021;45(5):1293-1296.
The World Health Organization (WHO) surgical safety checklist is widely used in surgical settings to prevent errors. This multinational panel representing multiple clinical specialties identified 16 recommendations for checklist content modification and implementation during the COVID-19 pandemic. These recommendations exemplify how the checklist can be adapted to meet urgent and emerging needs of surgical units by targeting important processes and encouraging critical discussions.
Kruse CS, Mileski M, Syal R, et al. Technol Health Care. 2020;29(1):1-14.
Health information technology (HIT) can promote patient safety in many settings. This systematic review found that HIT, such as computerized provider order entry (CPOE) systems, can improve safe prescribing practices in long-term care settings, including improved documentation and clinical processes, and fewer medication errors.
Bisbey TM, Kilcullen MP, Thomas EJ, et al. Hum Factors. 2021;63(1):88-110.
A culture of safety is a key component to successful, sustainable patient safety programs. The authors review existing models of safety culture and propose a framework which synthesizes information across fragmented concepts – including organizational culture, social identity, and social learning – to illustrate the dynamic nature and drivers of safety culture.
Gregory ME, Hughes AM, Benishek LE, et al. J Patient Saf. 2021;17(2):e47-e70.
High reliability remains an elusive goal for health care organizations. The authors of this study posit that medical teams’ ABCs – attitudes, behaviors, and cognitions – are critical for high-reliability, enhancing team adaptation and increasing patient safety. The article outlines practical tools and educational strategies that can be leveraged by a variety of healthcare organizations to improve team-based care.

Zeynep Tufekci. The Atlantic. February 26, 2021

Failures in communication have impacts on patients, teams, organizations and society. This article discusses five weaknesses in pandemic messaging that were counterproductive including use of shaming instead of empathy to engage the public, lack of detail on suggested strategies and insufficient advice to support public adoption of harm reduction activities.
Newspaper/Magazine Article

Caceres V. US News World ReportMarch 1, 2021.

Patients and families have an important role in reducing potential for error and harm. This article highlights a set of tactics for patients to enhance the safety of their care that include preparing for doctor’s appointments, asking questions and seeking second opinions.

The American Society for Dermatologic Surgery Association and the Northwestern University Department of Dermatology.

Voluntary reporting systems collect adverse event data to inform improvement and education efforts. This site provides a platform for physicians and their staff to submit adverse experiences associated with dermatologic surgery equipment, medications or biologics.

Quick Safety. March 2021;58:1-2.

The potential exposure to COVID-19 continues to negatively influence patient care seeking activity. This article recommends several strategies for gaining patient trust in the system to keep them safe from exposure which include dedicated spaces for preventative services and proactive encouragement on the importance of screenings such as mammograms.

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.