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April 7, 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

Chen Y-YK, Arriaga A. BMJ Qual Saf. 2021;Epub Mar 25.

Checklists and other cognitive aids are used in a variety of clinical settings to improve patient safety. Building on an example from emergency medicine, the authors highlight the importance of implementation science methods to ensure the most effective use of these cognitive aids.
Holm S, Stanton C, Bartlett B. Health Care Anal. 2021;Epub Mar 22.
Artificial intelligence (AI) is currently used to assist with many healthcare practices, including diagnosing cancer, detecting deterioration, and medication reconciliations. As the use of AI continues to expand, regulators and legal experts will need to consider how to manage compensation for patients who have experienced medical errors. This commentary suggests no-fault compensation as a possible solution. 
Omar I, Singhal R, Wilson M, et al. Int J Qual Health Care. 2021;33(1):mzab045.
Never events, a significant type of adverse event, should never occur in healthcare. This study analyzed 797 surgical never events that occurred from April 2012 to February 2020 in the National Health Service (NHS) England and categorized them into three main categories: wrong-site surgery (53.58%), retained items post-procedure (44.54%), and wrong implant/prosthesis (1.88%). In total 56 common general surgery never events have been found. Being aware of the common themes may help providers to develop more effective strategies to prevent these adverse events.
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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
Spotlight Case
Verna Gibbs, MD |
Two separate patients undergoing urogynecologic procedures were discharged from the hospital with vaginal packing unintentionally left in the vagina. Both cases are representative of the challenges of identifying and preventing retained orifice packing, the critical role of clear handoff communication, and the need for organizational cultures which encourage health care providers to communicate and collaborate with each other to optimize patient safety.
WebM&M Cases
Deborah Plante, MD, and Andrea Gonzalez Falero, MD |
A 24-year-old woman with type 1 diabetes presented to the emergency department with worsening abdominal pain, nausea, and vomiting. Her last dose of insulin was one day prior to presentation. She stopped taking insulin because she was not tolerating any oral intake. The admitting team managed her diabetes with subcutaneous insulin but thought the patient did not meet criteria for diabetic ketoacidosis (DKA), but after three inpatient days with persistent hyperglycemia, blurred vision, and altered mental status, a consulting endocrinologist diagnosed DKA. The patient was transferred to the intensive care unit (ICU) and an insulin drip was started, after which the patient’s metabolic derangements normalized and her symptoms resolved. The commentary discusses the importance of educating patients and providers on risk factors for DKA and symptoms in type 1 diabetics, the use of a stepwise approach to diagnosing acid-based disorders, clinical decision support tools to guide physiologic insulin replacement, and the role of closed-loop communication to decrease medical error.
WebM&M Cases
Stephen A. Martin, MD, EdM, Gordon D. Schiff, MD, and Sanjat Kanjilal, MD, MPH |
A pregnant patient was admitted for scheduled Cesarean delivery, before being tested according to a universal inpatient screening protocol for SARS-CoV-2. During surgery, the patient developed a fever and required oxygen supplementation. Due to suspicion for COVID-19, a specimen obtained via nasopharyngeal swab was sent to a commercial laboratory for reverse transcriptase polymerase chain reaction (RT-PCR) testing. However, due to delays in receiving those results, another sample was tested two days later with a newly developed in-house test, and a third sample was sent to the state public health laboratory. The in-house test returned as positive for SARS-CoV-2. The patient was discharged in stable clinical condition but was advised to quarantine for 14 days. Two days after the patient’s discharge, the commercial and state lab tests were both reported as negative. A root-cause analysis subsequently determined that the positive test run on the in-house platform was due to cross-contamination from a neighboring positive sample. The commentary discusses the challenges associated with SARS-CoV-2 testing, the unprecedented burden faced by health systems, and downstream consequences of false positive tests.
Kostopoulou O, Tracey C, Delaney BC. J Am Med Inform Assoc. 2021;Epub Mar 12.
In addition to being used for patient-specific clinical purposes, data within the electronic health record (EHR) may be used for other purposes including epidemiological research. Researchers in the UK developed and tested a clinical decision support system (CDSS) to evaluate changes in the types and number of observations that primary care physicians entered into the EHR during simulated patient encounters. Physicians documented more clinical observations using the CDSS compared to the standard electronic health record. The increase in documented clinical observations has the potential to improve validity of research developed from EHR data.
Johnson SM, Samulski TD, O’Connor SM, et al. Am J Clin Pathol. 2021;Epub Mar 27.
Newly diagnosed cancer patients may request second opinions to confirm diagnosis, treatment, or prognosis. This study evaluated the pathology-specific reimbursement for cases originating at the primary site, a comprehensive cancer center, and cases originating at affiliate sites and referred to the cancer center for second opinions. Results confirmed that second opinions can reduce diagnostic errors and potentially lower costs of subsequent treatment; however, ways to improve the cost and process of receiving a second opinion should be explored.
Omar I, Singhal R, Wilson M, et al. Int J Qual Health Care. 2021;33(1):mzab045.
Never events, a significant type of adverse event, should never occur in healthcare. This study analyzed 797 surgical never events that occurred from April 2012 to February 2020 in the National Health Service (NHS) England and categorized them into three main categories: wrong-site surgery (53.58%), retained items post-procedure (44.54%), and wrong implant/prosthesis (1.88%). In total 56 common general surgery never events have been found. Being aware of the common themes may help providers to develop more effective strategies to prevent these adverse events.
Macías-Colorado ME, Rodríguez-Pérez M, Rojas-Ocaña MJ, et al. Healthcare (Basel). 2021;9(2):205.
Clear communication between patients, family caregivers, and nurses is crucial to improve patient safety in the home. This qualitative study identified four key concepts around communication of safe family caregiving: communication-related aspects, professional skills of nurse case managers, communication on safety, and the caregiving role. The authors suggest five areas for research to improve patient safety in the home.   
Edrees HH, Wu AW. J Patient Saf. 2021;17(1):e247-e254.
Unanticipated adverse events harm not only patients, but also have the potential to cause psychological harm to the healthcare providers involved in the incident. This study investigated how Maryland hospitals currently support “second victims.” Even though all study participants agreed that organizations should offer support programs to second victims, they stated that several barriers exist, including stigma. Future research efforts should involve second victims themselves in order to identify barriers and facilitators, such as safety culture, to the use of organization support programs.
Volpi E, Giannelli A, Toccafondi G, et al. J Patient Saf. 2021;17(3):e143-e148.
Medication errors are a common and significant causes of patient harm. This retrospective study examined regional prescription registry (RPR) data at a single Italian hospital at 4 comparison points, pre-admission, admission, hospitalization, and post-discharge. Researchers identified 4,363 discrepancies among 14,573 prescriptions originating from 298 patients with a mean age of 71.2 years. Approximately one third of the discrepancies (1,310) were classified as unintentional and the majority (62.1%) of those were found when comparing the prescriptions during the transition from  hospital discharge and the 9-month follow up. The study points to the need for enhanced communication between hospitalists and primary care providers at the hospital-home interface.

Shannon EM, Zheng J, Orav EJ, et al. JAMA Network Open. 2021:4(3);e213474.

This cross-sectional study examined whether racial/ethnic disparities in interhospital transfers (IHT) for common medical diagnoses such as heart failure, acute myocardial infarction, stroke, and sepsis, impact mortality outcomes. The authors analyzed 899,557 patients and reported that Black patients had lower odds of IHT compared to White patients, while Hispanic patient had higher odds of IHT compared with White patients. The authors propose several possible explanations including differences in Black and Hispanic willingness to transfer, impact of insurance status and reimbursement rates, coding inaccuracies, and other complex dynamics for their findings.
Holm S, Stanton C, Bartlett B. Health Care Anal. 2021;Epub Mar 22.
Artificial intelligence (AI) is currently used to assist with many healthcare practices, including diagnosing cancer, detecting deterioration, and medication reconciliations. As the use of AI continues to expand, regulators and legal experts will need to consider how to manage compensation for patients who have experienced medical errors. This commentary suggests no-fault compensation as a possible solution. 
Harms-Ringdahl L. Safety. 2021;7(1):19.
The primary purpose of incident reporting and analysis is to propose safety reforms. This study reviewed three sets of event investigations (one from industrial companies and two from hospitals) using two methods of investigation (in-depth or root cause analysis). In-depth analysis resulted in more suggestions for reform targeted at the federal, regional, health system, or department level. Root cause analysis resulted in suggestions at the department or ward level. The authors conclude there is room for improvement in  in the management and performance of event investigations in the healthcare sector.

Chen Y-YK, Arriaga A. BMJ Qual Saf. 2021;Epub Mar 25.

Checklists and other cognitive aids are used in a variety of clinical settings to improve patient safety. Building on an example from emergency medicine, the authors highlight the importance of implementation science methods to ensure the most effective use of these cognitive aids.
O’Brien N, Ghafur S, Durkin M. J Patient Saf Risk Manag. 2021;26(1):5-10.
Planned and unplanned electronic heath record (EHR) downtime can have a negative effect on patient safety. This commentary recommends training and education for frontline healthcare workers to help manage cybersecurity attacks in health care. Interventions should be simple and easy to implement and could be based on lessons learned in other areas of patient safety, such as hand hygiene.
Filipescu D, Ştefan M. Best Pract Res Clin Anaesthesiol. 2021;35(1):141-153.
Transgender people are especially vulnerable in healthcare settings. Anesthesiologists are in a critical position to improve transgender patient outcomes by being aware of sex-related differences in physiology, pharmacokinetics, and pharmacodynamics. In addition to research characterizing outcomes of surgery between men and women, future research should address the role of women anesthesiologists in improving patient safety.
Srinivasamurthy SK, Ashokkumar R, Kodidela S, et al. Eur J Clin Pharmacol. 2021;77(8):1123-1131.
Computerized prescriber (or physician) order entry (CPOE) systems are widely used in healthcare and studies have shown a reduction in medication errors with CPOE. This study focused on whether CPOE systems improved the incidence of chemotherapy-related medication errors. The study included 11 studies in the review but only 8 studies were in the meta-analysis. The authors found that the use of CPOE was associated with an 81% reduction in chemotherapy-related medication errors, indicating that CPOE is a valuable strategy for this patient population.
Fiorinelli M, Di Mario S, Surace A, et al. Appl Nurs Res. 2021;58:151405.
Smartphones have become ubiquitous among healthcare professionals for both personal and patient care purposes. This review explored positive (improved performance; access to information about medications) and negative (distraction from core clinical tasks) consequences of nurses’ smartphone use during work. Healthcare workplaces should implement policies to restrict when and where smartphones can be used for personal purposes.
Zheng WY, Lichtner V, Van Dort BA, et al. Res Soc Admin Pharm. 2021;17(5):832-841.
This systematic review sought to determine the impact of automated dispensing cabinets (ADCs), barcode medication administration (BCMA), and closed-loop electronic medication management systems (EMMS) used by hospitals in reducing controlled substance medication errors in hospitals. Overall, only 4 studies (out of 16) focused directly on controlled medications. A variety of types of errors (e.g., log-in, data, entry, override) compromised patient safety. High-quality targeted research is urgently needed to evaluate the risks and benefits of medication-related technology.
No results.

Gangopadhyaya A. Washington DC: Urban Institute; March 29, 2021.

Racial inequities affect the safety of medical care. This report analyzed 2017 discharge records using patient safety measures from 26 states to identify differences in adverse events and hospital-acquired conditions in Black and White patients. The results suggest that hospital availability for admission may be a driver to safety for both Black and White patient populations and point toward policy solutions for disparity reduction.

Henigson J. Washington Post. March 26, 2021.

Misdiagnoses can persist due to heuristics, discontinuities, and implicit bias. This news story chronicles the experience of a patient misdiagnosed with a brain tumor. His condition was eventually discovered through communication with a physician whose experience with similar situations allowed the physician to identify the problem.

Preckel B, ed. Best Pract Res Clin Anaesthesiol. 2021;35(1):1-154.

The field of anesthesiology has realized impressive improvements in safety, yet challenges still exist in its practice. This special issue provides discussions on a variety of concerns that require continued effort, including use of early warning scores, differences associated with sex and gender, and use of incident reporting systems.

Constellation, Society to Improve Diagnosis in Medicine. 

The processes supporting safe and accurate diagnosis involve many steps that are prone to human error. This collaborative will engage teams to explore test result management and follow-up coordination to improve timeliness, collaboration, and communication to support safe care. The launch of the collaborative has been delayed due to COVID-19.

This Month’s Perspectives

Jose Morfin Headshot
Interview
José A, Morfín, MD, FASN, is a health sciences clinical professor at the University of California Davis School of Medicine. In his professional role, he serves as the Medical Director for Satellite Health Care and as a member of the Medical Advisory Board for Nx Stage Medical. We discussed with him home dialysis and patient safety considerations.
Perspectives on Safety
This piece discusses how the program mitigates safety risks for in-home dialysis and the potential for in-home programs to greatly expand.