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April 14, 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

Chopra V, O'Malley M, Horowitz J, et al. BMJ Qual Saf. 2021;Epub Mar 29.
Peripherally inserted central catheters (PICC) represent a key source of preventable harm. Using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), the authors sought to determine if the appropriateness of PICC use decreased related medical complications including catheter occlusion, venous thromboembolism, and central line-associated bloodstream infections. Use of MAGIC in 52 Michigan hospitals increased appropriate use of PICC lines and decreased medical complications. In a 2019 PSNet Perspective, Dr. Vineet Chopra described the development and implementation of MAGIC in Michigan hospitals.  
Aaberg OR, Hall-Lord ML, Husebø SIE, et al. BMC Health Serv Res. 2021;21(1):114.
TeamSTEPPS is a patient safety intervention designed to improve teamwork and communication in healthcare settings. One Norwegian hospital utilized TeamSTEPPS to improve professional and organizational outcomes in the urology and gastrointestinal surgery ward. Twelve months after implementation, researchers observed sustained improvements in three patient safety culture dimensions and three teamwork dimensions. Further studies with larger same size and stronger study designs are warranted.
Vasey B, Ursprung S, Beddoe B, et al. JAMA Network Open. 2021;4(3):e211276.
This study explored the role of machine-learning based clinical decision support (CDS) algorithms to support (rather than replace) human decision-making and the impact on diagnostic performance. This systematic review of 37 studies found limited evidence that the use of machine learning-based CDS systems contributes to improved diagnostic performance among clinicians. Interobserver agreement, user feedback, and clinician override were the most commonly reported outcomes. The authors emphasize the importance of further evaluation of human-computer interaction.
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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.
Aaberg OR, Hall-Lord ML, Husebø SIE, et al. BMC Health Serv Res. 2021;21(1):114.
TeamSTEPPS is a patient safety intervention designed to improve teamwork and communication in healthcare settings. One Norwegian hospital utilized TeamSTEPPS to improve professional and organizational outcomes in the urology and gastrointestinal surgery ward. Twelve months after implementation, researchers observed sustained improvements in three patient safety culture dimensions and three teamwork dimensions. Further studies with larger same size and stronger study designs are warranted.
Carvalho IV, Sousa VM de, Visacri MB, et al. Pediatr Emerg Care. 2021;37(4):e152-e158.
This study sought to determine the rate of pediatric emergency department (ED) visits due to adverse drug events (ADE). Of 1,708 pediatric patients, 12.3% were admitted to the ED due to ADEs, with the highest rates of admission due to neurological, dermatological, and respiratory medications. The authors recommend the involvement of clinical pharmacists to prevent and identify ADEs in the pediatric population, particularly through education of children’s caregivers and health professionals.
Jansen I, Stalmeijer RE, Silkens MEWM, et al. Med Educ. 2021;Epub Feb 5.
Research on medical resident help-seeking behaviors has tended to focus on the relationship between residents and their supervisors. This study explored how the workplace environment and interprofessional team characteristics influence residents’ decisions to seek help. Three workplace factors influenced their decisions: a safe learning environment, relationship with their supervisors, and approachability of team members. Supervisors should have regular conversations with residents about factors that negatively impact their help-seeking behaviors. 
Gray BM, Vandergrift JL, McCoy RG, et al. BMJ Open. 2021;11(4):e041817.
Ambulatory and primary care are high risk settings for diagnostic errors. This retrospective study examined internal medicine physicians’ performance on diagnostic questions on board certification exams and found that higher diagnostic knowledge was associated with lower risk of adverse outcomes after patient visits for conditions sensitive to diagnostic error (e.g., stroke, pneumonia, pulmonary embolism).
Bentley SK, McNamara S, Meguerdichian MJ, et al. Adv Simul (Lond). 2021;6(1):9.
Debriefing is a communication strategy for teams to improve patient safety by learning from critical events, reducing reoccurrences, and improving processes. The authors developed and pilot-tested a debriefing tool to broaden the traditional focus of debriefs from “what went wrong” to also include what went right. In three debriefs conducted without the new tool, teams discussed an average of 14 topics; in three debriefs using the new tool, an average of 21 topics were discussed.  The authors propose debriefing when things go right will increase debriefings overall.
Küng K, Aeschbacher K, Rütsche A, et al. Int J Qual Health Care. 2021;33(1).
Barcode medication administration (BCMA) systems are one strategy to reduce medication administration time and preparation errors. This study sought to assess the influence of BCMA on the rate of medication preparation errors and time spent by registered nurses on medication preparation tasks. Use of BCMA decreased wrong medication and wrong dosage errors, and wrong patient, wrong form, and ambiguous dispenser errors did not occur post-intervention. Additionally, BCMA decreased medication preparation time.
Renecle M, Curcuruto M, Gracia Lerín FJ, et al. Safety Science. 2021;138:105197.
Mindful organizing is a key feature of high reliability organizations. This article explores the contextual, team level variables important for fostering mindful organizing, how individuals and teams engage mindful organizing to ensure safety, and the mediating effect of mindful organizing between safety climate and individual safety behavior.
Omar I, Graham Y, Singhal R, et al. World J Surg. 2021;45(3):697-704.
Never events can result in serious patient harm and indicate serious underlying organizational safety problems. This study analyzed never events occurring between 2012 and 2020 in the National Health Services and categorized 51 common never events into four categories – wrong site surgery (40% of events); retained foreign objects post-procedure (28%); wrong implant/prosthesis (13%); and non-surgical/infrequent never events (19%). Awareness of these themes may support focused efforts to reduce their incidence and development of specific local safety standards. 
Chopra V, O'Malley M, Horowitz J, et al. BMJ Qual Saf. 2021;Epub Mar 29.
Peripherally inserted central catheters (PICC) represent a key source of preventable harm. Using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), the authors sought to determine if the appropriateness of PICC use decreased related medical complications including catheter occlusion, venous thromboembolism, and central line-associated bloodstream infections. Use of MAGIC in 52 Michigan hospitals increased appropriate use of PICC lines and decreased medical complications. In a 2019 PSNet Perspective, Dr. Vineet Chopra described the development and implementation of MAGIC in Michigan hospitals.  
Øyri SF, Braut GS, Macrae C, et al. J Patient Saf. 2021;17(2):122-130.
This qualitative study conducted in Norway explored how changes in hospital supervision due to new quality improvement regulations and regulatory inspectors’ work, promote or hamper resilience and learning in hospitals. Based on interviews and focus groups with regulatory inspectors, the authors suggest that the government should encourage regulators and local policymakers to communicate positive experiences and smart adaptations in hospital practice.
Alboksmaty A, Kumar S, Parekh R, et al. PLoS One. 2021;16(3):e0248387.
Older adults, especially older adults with multimorbidities, are at increased risk of severe illness or death from COVID-19. General practitioners (GPs) in the UK were interviewed about how COVID-19 policies affected care of older adult patients with multimorbidities in their practices. Five major themes emerged: changes in primary care, involvement of GPs in policy making, communication and coordination, worries and stressors, and suggestions for improvement across the first four themes. COVID-19 policies have provided opportunities to continue providing safe healthcare for older adults with medical complexities, but they also highlight possible areas for improvement.
Campbell AA, Harlan T, Campbell M, et al. J Nurs Scholarsh. 2021;Epub Apr 1.
Using electronic health records, call light systems, and bar-code medication administration systems, this study examined the impact of six specific workload variables on nurses’ medication administration errors. At least one of the six variables was significantly associated with the occurrence or nonoccurrence of a near miss medication error in the majority of nurses. Because the specific variable(s) differed for each individual nurse, interventions addressing medication administration errors should be tailored to individual nurse risk factors.
Schouten B, Merten H, Spreeuwenberg PMM, et al. J Patient Saf. 2020;17(3):166-173.
Prior research has estimated that 6% of patients receiving medical care experience preventable harm. This study compared the incidence and preventability of adverse events in older patients over an eight-year period (2008-2016). Findings indicate that while the incidence of adverse events declined across the time period, the preventability of the events did not. The authors posit that this could be due to crowding or increasing care complexity due to age, frailty, comorbidities, or polypharmacy.
Sloane PD, Yearby R, Konetzka RT, et al. J Am Med Dir Assoc. 2021;22(4):886-892.
Racial bias and racism are increasingly seen as a critical patient safety issue. In this article, the authors outline the components of systemic racism (structural/institutional, cultural, and interpersonal), how they manifest and affect the long-term care system, and the detrimental impact of systemic racism on Blacks during the COVID-19 pandemic.
Vasey B, Ursprung S, Beddoe B, et al. JAMA Network Open. 2021;4(3):e211276.
This study explored the role of machine-learning based clinical decision support (CDS) algorithms to support (rather than replace) human decision-making and the impact on diagnostic performance. This systematic review of 37 studies found limited evidence that the use of machine learning-based CDS systems contributes to improved diagnostic performance among clinicians. Interobserver agreement, user feedback, and clinician override were the most commonly reported outcomes. The authors emphasize the importance of further evaluation of human-computer interaction.
No results.

Jurecko L. Consult QD. March 16, 2021.

Leadership actions reinforce organizational efforts to enhance health care safety. This article summarizes foundational concepts for leaders to adopt in order to enhance their work toward achieving high reliability. The author suggests that leadership should embrace certain attitudes including blame reduction, complexity consideration and partnering with patients.

Issue Brief. Washington DC: Pew Charitable Trust; March 2021.

Antibiotic overuse is a contributor to nosocomial infection. This report discusses problems associated with antibiotic prescribing during the first 6 months of the COVID-19 pandemic. Systemic problems arising from the situation include disparities associated with antibiotic administration and unneeded receipt of medications by some patients.

Chicago, IL: Accreditation Council for Graduate Medical Education; March 2021.

Clinician well-being is a cornerstone to safe care delivery. This report summarizes a leadership discussion examining systemic factors that detract from healthcare workforce wellness, current strategies to address those factors, and barriers to improvement.

Peikoff L. NBC News. March 31, 2021.

Patients with endometriosis often experience care delays and misdiagnoses that contribute to harm. This news story discusses a patient’s experience with common contributors to delay that include Insufficient clinical knowledge of the disease and a lack of uniform treatment guidance.

Chicago, IL: Society to Improve Diagnosis in Medicine; March 2021.

Telehealth is commonly used to deliver health care, yet its safety across the continuum has yet to be determined. This report highlights perspectives on the potential of telediagnosis and examines its reach, effectiveness, adoption, implementation, and maintenance, to inform actions to ensure its safe use.

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.