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April 21, 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

Dancsecs KA, Nestor M, Bailey A, et al. Am J Emerg Med. 2021;47:90-94.
Alteplase and other thrombolytics are high-alert medications. This study compared error rates of alteplase administration in patients presenting with acute ischemic stroke at either a regional hospital or a Comprehensive Stroke Center (CSC) and found that community hospitals had over a 10 times greater number of errors leading to hemorrhage. The study recommend to put safeguards in place to decrease the risk of alteplase medication administration errors.
Funke M, Kaplan MC, Glover H, et al. Jt Comm J Qual Patient Saf. 2021;47(6):364-375.
Despite local, state, and national efforts, opioid misuse and overdose remains a public health concern. One strategy to reduce overdose is concurrent prescription of naloxone. This article describes how one emergency department (ED) used staff education to promote a naloxone Best Practice Advisory (BPA) and order set in the electronic health record, amongst other interventions. The BPA significantly increased naloxone prescribing for patients identified as having opioid overdose or misuse diagnoses. Similar high-reliability EMR work-aids and staff education strategies could be implemented in other EDs to increase naloxone prescriptions.
Stevens EL, Hulme A, Salmon PM. Ergonomics. 2021;Epub Mar 30.
Power dynamics can influence effective team performance and patient safety. This systematic review examined the influence of actual or perceived ‘power’ on teamwork within multidisciplinary healthcare settings. Findings indicate that power imbalances can result in negative effects on team collaboration, decision-making, communication, and performance. An April 2020 WebM&M commentary discusses the effect of power dynamics on interprofessional healthcare teams.
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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.
Cattaneo D, Pasina L, Maggioni AP, et al. Drugs Aging. 2021;38(4):341-346.
Older adults are at increased risk of hospitalization due to COVID-19 infections. This study examined the potential severe drug-drug interactions (DDI) among hospitalized older adults taking two or more medications at admission and discharge. There was a significant increase in prescription of proton pump inhibitors and heparins from admission to discharge. Clinical decision support systems should be used to assess potential DDI with particular attention paid to the risk of bleeding complications linked to heparin-based DDIs.
Dancsecs KA, Nestor M, Bailey A, et al. Am J Emerg Med. 2021;47:90-94.
Alteplase and other thrombolytics are high-alert medications. This study compared error rates of alteplase administration in patients presenting with acute ischemic stroke at either a regional hospital or a Comprehensive Stroke Center (CSC) and found that community hospitals had over a 10 times greater number of errors leading to hemorrhage. The study recommend to put safeguards in place to decrease the risk of alteplase medication administration errors.
Funke M, Kaplan MC, Glover H, et al. Jt Comm J Qual Patient Saf. 2021;47(6):364-375.
Despite local, state, and national efforts, opioid misuse and overdose remains a public health concern. One strategy to reduce overdose is concurrent prescription of naloxone. This article describes how one emergency department (ED) used staff education to promote a naloxone Best Practice Advisory (BPA) and order set in the electronic health record, amongst other interventions. The BPA significantly increased naloxone prescribing for patients identified as having opioid overdose or misuse diagnoses. Similar high-reliability EMR work-aids and staff education strategies could be implemented in other EDs to increase naloxone prescriptions.
Dutra CK dos R, Guirardello E de B. J Adv Nurs. 2021;77(5):2398-2406.
This cross-sectional study describes the relationship between nurse work environment and missed nursing care, safety culture, and job satisfaction. Nurses who perceived a positive work environment reported reduced reasons for missed nursing care, an improved safety culture, and increased job satisfaction. Reasons for missed care were primarily related to lack of leadership support and resources. Nurse managers can increase perception of a positive work environment by providing additional support and adequate human and material resources.
Thomas AN, Balmforth JE. J Patient Saf. 2021;17(2):e71-e75.
Patient falls represent a serious source of preventable harm. The authors reviewed patient safety incidents in critical care units in England between 2009 and 2017 and found that a small proportion (2%) involved a fall. Common factors involved in fall incidents included patients attempting tasks without assistance, patient confusion, and staff being away from the patient. Harm to patient or staff occurred in 22% of falls.
Dürr P, Schlichtig K, Kelz C, et al. J Clin Oncol. 2021;Epub Apr 7.
Patients taking oral anti-cancer drugs may experience severe side effects and medication errors. In this randomized controlled study, patients taking oral chemotherapy drugs were randomized to receive usual care (control) or additional intensive pharmacological/pharmaceutical care (intervention). Patients in the intervention group reported considerably fewer medication errors and side effects and increased treatment satisfaction.
Waldron KM, Schenkat DH, Rao KV, et al. Am J Health-Syst Pharmacy. 2021;78(7):552-555.
Health systems have needed to rapidly adapt processes to optimize safe care during the COVID-19 pandemic. This article describes one pharmacy department’s experience integrating emergency preparedness and disaster management principles during the COVID-19 pandemic, including the use of a department-specific incident command and delineation of responsibilities among pharmacy leadership (e.g., who monitors PPE inventory, medication distribution, workflows).
Brownlee SM, Korenstein D. BMJ. 2021;372:n117.
Overuse of healthcare services can result in financial, physical, and emotional harm to the patient. If patients and clinicians better understood the risk of potential harms due to overuse, preventable harms may be reduced. Research is needed to quantify harm resulting from overuse of healthcare services, including the number of patients harmed and how serious the harms are.  
Du L, Murdoch B, Chiu C, et al. J Patient Saf. 2021;17(3):200-206.
Ensuring research participants’ confidentiality is of paramount importance to conducting patient safety research. This article explores how confidentiality is presented in informed consent templates, as compared to current case law in Canada and the United States. Researchers should continue to reassure participants that attempts to force disclosure of confidential research information are rarely successful, and describe the steps taken to protect their confidentiality.
Sterling RS, Berry SA, Herzke CA, et al. Am J Med Qual. 2021;36(1):57-59.
The COVID-19 pandemic has necessitated rapid adjustments in hospital operations to address patient care demands. This commentary discusses how one hospital system utilized their quality and safety staff during the pandemic, and how that experience informed the responsiveness of system-wide quality improvement operations.

Roy CG. Yale J Biol Med. 2021;94(1):165-173. 

Delivery of safe care hinges on the competency of medical professionals. This article outlines the origins of state medical board systems in the United States and their evolving role in promoting patient safety based on IOM recommendations, including re-examination for licensure and specialty board certification, reporting, and monitoring.
Petersen C, Smith J, Freimuth RR, et al. J Amer Med Inform Assoc. 2020;28(4):677-684.
Clinical decision support (CDS) systems are intended to support diagnosis and therapeutic processes of care. This position paper defines adaptive CDS as “systems that can learn and change performance over time, incorporate new clinical evidence, data types, data sources, and methods for interpreting data.” Recommendations for the effective management and monitoring of adaptive CDS are outlined.
Jt Comm J Qual Saf. 2021;47(6):394-397.
Smart infusions pumps with built-in dose error reduction software (DERS) are designed to protect against dosing errors that result in patient harm. This alert summarizes recommendations to enhance the effective implementation and use of smart infusion pumps such as drug library maintenance and pump error report monitoring.
Quinn TP, Senadeera M, Jacobs S, et al. J Amer Med Inform Assoc. 2021;28(4):890-894.
Artificial intelligence (AI) has the potential to enhance safety and improve diagnosis, but its use is not without risks and challenges. This article discusses the conceptual, technical, and humanistic challenges with AI in health care and how AI developers, validators, and operational staff can help overcome these challenges.
Lippke S, Derksen C, Keller FM, et al. Int J Environ Res Public Health. 2021;18(5):2616.
Communication is an essential component of safe patient care. This review of 71 studies found that communication training interventions in obstetrics can improve communication skills and behavior, particularly when combined with team training. The authors identified a lack of evidence regarding the effect of communication trainings on patient safety outcomes and suggest that future research should assess this relationship. Study findings underscore the need for adequate communication trainings to be provided to all staff and expectant mothers and their partners.
Gopal DP, Chetty U, O'Donnell P, et al. Future Healthc J. 2021;8(1):40-48.
Provider implicit bias can impact patient safety through clinical misdiagnosis, pain management, and poor patient outcomes. This literature review sought to define implicit bias and identify the impact on clinical practice and research. The authors found that no effective debiasing strategies seem to currently exist. A December 2020 WebM&M commentary discusses how implicit bias can contribute to poor communication between healthcare teams.
Stevens EL, Hulme A, Salmon PM. Ergonomics. 2021;Epub Mar 30.
Power dynamics can influence effective team performance and patient safety. This systematic review examined the influence of actual or perceived ‘power’ on teamwork within multidisciplinary healthcare settings. Findings indicate that power imbalances can result in negative effects on team collaboration, decision-making, communication, and performance. An April 2020 WebM&M commentary discusses the effect of power dynamics on interprofessional healthcare teams.
Upcoming Meeting/Conference

Armstrong Institute for Patient Safety and Quality. September 23-24, 2021.

The comprehensive unit-based safety program (CUSP) approach emphasizes active teamwork as a core element of improving safety culture through reporting and learning from errors. This virtual conference will cover how to engage teams in the ambulatory environment, address barriers to safe care, and learn from the experiences of others.
Multi-use Website

Centers for Disease Control and Prevention.

Ethnic and social inequities have a substantial impact on the safety and effectiveness of health care. This US Centers for Disease Control and Prevention (CDC) initiative provides access to science, CDC actions, and expert insights on the value of public health efforts to reduce the impact of systemic racism on health in the United States.

Wantagh, NY; Pulse Center for Patient Safety, Education & Advocacy.

Patients can be active partners in their own safe care. This five-step program provides information and education for patients on topics such as advance directives, medication records, and visit preparation as strategies to improve patient safety.

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.