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March 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

Bae S‐H. J Clin Nurs. 2021;Epub Feb 23.
The relationship between resident and physician duty hours and patient safety has been the focus of a lot of research. The relationship between nurse work schedules and patient safety is less explored. This review investigated the effect of extended or excessive nurse schedules on patient outcomes. Findings conclude that working more than 12 hours daily or more than 40 hours weekly may contribute to adverse patient outcomes. The authors recommend creating policies restricting nurse shifts to no more than 12 hours per day and 40 hours per week.
Fridrich A, Imhof A, Schwappach DLB. J Patient Saf. 2021;17(3):217-222.
Checklists are used across clinical areas. Following the publication of the World Health Organization’s (WHO) Surgical Safety Checklist in 2009, other organizations developed their own checklists or adapted the WHO Surgical Safety Checklist for local settings. The authors analyzed 24 checklists used in 18 Swiss hospitals, identified major differences between study checklists and reference checklists and provided recommendations for future research regarding the effectiveness of surgical safety checklists. 
Muensterer OJ, Kreutz H, Poplawski A, et al. BMJ Qual Saf. 2021;30(8):622-627.
Preoperative checklists and timeouts are common tools to improve patient safety. Over a 16-month period, this study purposefully and randomly introduced errors during preoperative timeouts for 1,800 procedures but only 54% of these errors were reported by operating team members. The authors suggest that future research should explore ways to improve the quality of surgical timeouts to reduce risks to patient safety.
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PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. Sign up today to get weekly and monthly updates via emails!

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.
LaGrone LN, McIntyre LK, Riggle A, et al. J Trauma Acute Care Surg. 2020;89(6):1046-1053.
The authors examined contributors to error-associated deaths occurring between 1996-2004 and 2005-2014 and identified a shift from deaths occurring during the early phase of care (e.g., failed resuscitation and hemorrhage) to deaths occurring during the recovery phase (e.g., respiratory failure from aspiration). These findings demonstrate that successful implementation of system improvements can resolve process of care issues, but that ongoing evaluation is critical for continuous process improvement.
D’Amore JD, McCrary LK, Denson J, et al. J Am Med Inform Assoc. 2021;28(7):1534-1542.
Quality measurement is increasingly being incorporated into policies outlining healthcare provider reimbursement. This study compared quality measure calculations between an individual electronic health record (EHR) source and the same EHR source combined with health information exchange (HIE) data. The results show that adding HIE data changed 15% of quality measure calculations. The authors suggest that incorporating HIE data into reimbursement programs could promote more accurate and representative quality measurement.
Booth JP, Kennerly-Shah JM, Hartman AD. J Oncol Pharm Pract. 2021;Epub Feb 23.
The American Society of Clinical Oncology/Oncology Nursing Society and the Institute for Safe Medication Practices (ISMP) recommend independent double checks for certain medications In this retrospective study, pharmacists performed independent double checks on 1,645 anti-cancer parenteral orders. Pharmacists identified 30 errors during the first verification, and 10 errors on the second, resulting in a 33.3% increase in corrected errors.  
ten Haken I, Ben Allouch S, van Harten WH. Nurse Educ Today. 2021;100:104813.
Adverse events are common among patients receiving home care, particularly among those requiring complex medication dosing or use of infusion devices. Results from a survey administered to home care nurses in the Netherlands reveal that nurses may not receive practical training or be tested in required skills for the use of advanced medical technologies, such as infusion therapy, parenteral nutrition, or morphine pumps.
Li E, Marrandino J, Marshall S, et al. Int J Clin Pharm. 2021;Epub Jan 31.
National organizations have undertaken efforts to eliminate the use of error-prone abbreviations to reduce medication errors. This study found that pharmacy staff audits may under-report use of these “do not use” abbreviations, which may limit the effectiveness of audit systems and place patients at risk for harm. 
Fridrich A, Imhof A, Schwappach DLB. J Patient Saf. 2021;17(3):217-222.
Checklists are used across clinical areas. Following the publication of the World Health Organization’s (WHO) Surgical Safety Checklist in 2009, other organizations developed their own checklists or adapted the WHO Surgical Safety Checklist for local settings. The authors analyzed 24 checklists used in 18 Swiss hospitals, identified major differences between study checklists and reference checklists and provided recommendations for future research regarding the effectiveness of surgical safety checklists. 
Goh HS, Tan V, Chang J, et al. J Nurs Care Qual. 2021;Epub Feb 24.
Incident reporting systems are a common method for hospitals to detect patient safety events, but prior research has questioned whether these systems improve outcomes. Conducted in a nursing home, this study found that an existing incident reporting system redesigned to facilitate double-loop learning could improve nurses’ patient safety awareness and workplace practices, which could improve patient outcomes and safety.
Miller AC, Arakkal AT, Koeneman S, et al. BMJ Open. 2021;11(2):e045605.
Delayed diagnosis is a critical patient safety concern. This cohort study, consisting of 3,500 patients with tuberculosis (TB) over a 17-year period, found that more than three-quarters of patients experienced at least one missed opportunity for a diagnosis in the year before they were finally diagnosed with TB. The average duration of the diagnostic delay was nearly 32 days. Missed opportunities occurred most commonly in outpatient settings. A previous WebM&M commentary discusses patient harm resulting from a missed TB diagnosis.
Sprogis SK, Street M, Currey J, et al. Aust Crit Care. 2021;Epub Mar 14.
Medical emergency teams (MET), also known as rapid response teams, are used to improve the identification and management of patients demonstrating signs of rapid deterioration. This study found that modifying activation criteria to trigger METs at more extreme levels of clinical deterioration were not associated with negative patient safety outcomes.
Geller AI, Conrad AO, Weidle NJ, et al. Pharmacoepidemiol Drug Saf. 2021;30(5):573-581.
The Institute for Safe Medication Practices (ISMP) classifies insulin as a high-risk medication. This study examines insulin mix-up errors that resulted in emergency department visits or other serious adverse events. Most cases of medication mix-up involved rapid-acting insulin. Recommended prevention strategies include increased patient education and human factors engineering.
Harper A, Kukielka E, Jones RM. Patient Safety. 2021;3(1):10-22.
Although medication reconciliation is a common strategy to improve medication safety, barriers to implementation and threats to safety persist. Based on events reported to the Pennsylvania Patient Safety Reporting System, the authors characterized serious events related to medication reconciliation. The most common process failures contributing to patient harm occurred during order entry/transcription and resulted most frequently in the wrong dose or dose omission. The authors suggest risk reduction strategies including defined clinician roles for medication reconciliation, listing the indication for prescribed medications, and adding anticonvulsants to processes for medication with high risk for harm.
Lee G, Clough OT, Walker JA, et al. Patient Safety Surg. 2021;15(1):11.
In an effort to continue planned and elective procedures during the COVID-19 pandemic, the National Health Service utilized alternate “clean” hospital sites which did not admit or treat patients with COVID-19. This study found that although patient concerns about undergoing elective procedures during the COVID-19 pandemic were common, the majority of these patients reported high levels of confidence and satisfaction in the precautions in place at these “clean” sites to protect their safety.
Muensterer OJ, Kreutz H, Poplawski A, et al. BMJ Qual Saf. 2021;30(8):622-627.
Preoperative checklists and timeouts are common tools to improve patient safety. Over a 16-month period, this study purposefully and randomly introduced errors during preoperative timeouts for 1,800 procedures but only 54% of these errors were reported by operating team members. The authors suggest that future research should explore ways to improve the quality of surgical timeouts to reduce risks to patient safety.
Yousef EA, Sutcliffe KM, McDonald KM, et al. Hum Factors. 2021:001872082199618.
Safe diagnosis is a complex challenge requiring multidisciplinary approaches. The authors of this article apply high-reliability organization principles to the National Academy of Medicine (NAM) diagnostic process. The goal was to identify diagnostic challenges as well as strategies and solutions that diagnostic teams and organizations can use to optimize the diagnostic process and improve patient outcomes.
Bae S‐H. J Clin Nurs. 2021;Epub Feb 23.
The relationship between resident and physician duty hours and patient safety has been the focus of a lot of research. The relationship between nurse work schedules and patient safety is less explored. This review investigated the effect of extended or excessive nurse schedules on patient outcomes. Findings conclude that working more than 12 hours daily or more than 40 hours weekly may contribute to adverse patient outcomes. The authors recommend creating policies restricting nurse shifts to no more than 12 hours per day and 40 hours per week.

Boston Children’s Hospital. April 15, 2021. 

A core tenant of patient safety improvement is to draw from the experiences of a range of high-risk industries to address system safety barriers. This session focused on adaptations that health care has made in response to the COVID-19 pandemic. Dr. Don Berwick is among the featured speakers.

ISMP Medication Safety Alert! Acute Care. March 11, 2021;26(5):1-6.

Skin patches are a convenient medication delivery method but may harbor unique threats to safety. This article examines transdermal patch errors submitted to a national reporting program to provide safety improvement insights. Recommendations suggested for improvement focus on topics such as prescribing, patch management upon hospital admission, and labeling issues.

Brooks M. Medscape Medical News. March 15, 2021.

Safe care is influenced by both global and local changes in the environment. This news story summarizes a prioritized list of patient safety concerns--many of which were heightened due to the COVID-19 pandemic. Inequities due to ethnicity, lack of emergency readiness and ineffective pandemic readiness are highlighted.

Silver-Greenberg J, Gebeloff R. New York Times. March 13, 2021.

The value of rating systems can be challenged by bias and misinterpretation due to a variety of factors. This article outlines how nursing home patients fell victim to both systemic and care failings in the US nursing homes, yet their facilities still ranked high in a national rating system. The authors discuss failures including the lack of data auditing and a focus on ratings rather than quality.

AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021. 

Human factors engineering approaches improve safety, efficiency, and effectiveness in both normal and challenging times. This tool shares a human-factors structured approach to improving technology integration and adaptation into work processes to reduce burnout and its negative effects on worker and clinician wellbeing. 

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.