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April 28, 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

Cifra CL, Custer JW, Singh H, et al. Pediatr Crit Care Med. 2021;Epub April 10.
Diagnostic errors continue to be a patient safety concern, including in pediatric critical care. This systematic review explored the prevalence, impact, and contributing factors to diagnostic errors in the pediatric intensive care unit (PICU). The most common diagnostic errors occurred in cardiovascular, infectious, congenital, and neurologic conditions; cognitive and systems factors were associated with diagnostic errors. Future research should focus on disease- and systems-level determinants. 
Field TS, Fouayzi H, Crawford S, et al. J Am Med Dir Assoc. 2021;Epub Apr 1.
Transitioning from hospital to nursing home (NH) can be a vulnerable time for patients. This study looked for potential associations between adverse events (AE) for NH residents following hospital discharge and NH facility characteristics (e.g., 5-star quality rating, ownership, bed size). Researchers found few associations with individual quality indicators and no association between the 5-star quality rating or composite quality score. Future research to reduce AEs during transition from hospital to NH should look beyond currently available quality measures.
McCarthy C, Meaney S, Rochford M, et al. J Patient Saf Risk Manag. 2021;26(2):56-63.
Labor and delivery wards are high-risk care environments. This mixed-methods study found that risk (characterized as harm, danger, hazards, or uncertainty) is a common experience in labor wards. Study participants commonly used debriefing as an important practice following a risk experience. The authors highlight the need for risk reduction strategies, staff support, and training to ensure staff wellbeing in stressful situations.
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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.
Cicci CD, Fudzie SS, Campbell-Bright S, et al. Am J Health Syst Pharm. 2021;78(8):736-742.
When patients are admitted to the intensive care unit, medication histories can be obtained from alternate sources. In this study, admission medication histories were obtained from family members or outpatient pharmacies, then compared with the history given by the patient once their delirium resolved or they were extubated. The most common type of discrepancy from both alternate sources was addition, followed by omission. Histories obtained from families had slightly fewer discrepancies, and most discrepancies were of low risk of harm.  
Danielis M, Destrebecq A, Terzoni S, et al. Dimens Crit Care Nurs. 2021;40(3):186-191.
While the effectiveness of medical emergency teams (MET) has been widely researched, critical incidents that occur during the response have not received the same attention. This retrospective study analyzed critical incidents that occurred during MET responses over a five-year period. They mainly occurred due to lack of compliance with protocols and lack of available supplies. Educational and organizational strategies may be effective in reducing critical events during MET.
Zhang L, Losin EAR, Ashar YK, et al. J Pain. 2021;Epub Mar 9.
Unconscious assumptions and implicit biases can compromise both clinician decision making and patient outcomes. This article describes two experimental studies exploring the impact of gender biases on pain estimation and treatment recommendations. After controlling for self-reported pain, the first study found that female patients’ pain was under-estimated compared to male patients. The second study replicated these findings and also found that pain-related gender stereotypes (specifically about typical willingness to express pain between females vs males) predicted pain estimation biases and that female patients were judged to benefit more from psychotherapy, whereas male patients were judged to benefit more from pain medicine.
Henn P, O’Tuathaigh C, Keegan D, et al. J Patient Saf. 2021;17(3):e155-e160.
Hearing impairment can lead to misunderstanding of a patient’s health condition, treatment, or follow up care. Patients with hearing loss frequently misheard, misunderstood, or misinterpreted information given to them from a nurse or physician in both hospital and ambulatory settings. Health systems and clinicians should find ways to identify patients with hearing loss and develop alternate methods to communicate, such as visual aids, quiet environments, and lip reading communication.
van Heesch G, Frenkel J, Kollen W, et al. Jt Comm J Qual Patient Saf. 2020;47(4):234-241.
Poor handoff communication can threaten patient safety. In this study set in the Netherlands, pediatric residents were asked to develop a contingency plan for patients received during handoffs and asked to recall information from that handoff five hours later. Results indicate that engaging in deliberate cognitive processing during handoffs resulted in better understanding of patients’ problems, which could contribute to improved patient safety.
Sugrue A, Sanborn D, Amin M, et al. Am J Cardiol. 2020;144:52-59.
Anticoagulants are common medications that carry the potential for serious harm if administered incorrectly. This retrospective review of 8,576 patients with atrial fibrillation who received direct oral anticoagulants identified inappropriate dosing in nearly 15% of cases, with most patients receiving an inappropriately low dose. Over one year of follow-up, the authors did not identify any significant difference in the incidence of stroke, embolism, bleeding, or ischemic attacks between patients who were inappropriately, versus appropriately, dosed.
Massa S, Wu J, Wang C, et al. Jt Comm J Qual Patient Saf. 2021;47(4):242-249.
The objective of this mixed methods study was to characterize training, practices, and preferences in interprofessional handoffs from the operating room to the intensive care unit (OR-to-ICU). Anesthesia residents, registered nurses, and advanced practice providers indicated that they had not received enough preparation for OR-to-ICU handoffs in their clinical education or on-the-job training. Clinicians from all professions noted a high value of interprofessional education in OR-to-ICU handoffs, especially during early degree programs would be beneficial.
de Vos MS, Hamming JF, Marang-van de Mheen PJ. J Patient Saf. 2021;17(3):231-238.
Morbidity and mortality (M&M) conferences are a useful tool for teams to investigate and learn from adverse events. In this observational study, researchers interviewed clinicians attending surgical M&M conferences to explore the types, and recurrence of, lessons learned. Clinicians ascribed most lessons to technical or individual-level issues, and observed the challenges to sustaining changes at a systems-level. Researchers suggest M&M formats should shift to a broader focus to implement and sustain lasting system-level improvements.
McCarthy C, Meaney S, Rochford M, et al. J Patient Saf Risk Manag. 2021;26(2):56-63.
Labor and delivery wards are high-risk care environments. This mixed-methods study found that risk (characterized as harm, danger, hazards, or uncertainty) is a common experience in labor wards. Study participants commonly used debriefing as an important practice following a risk experience. The authors highlight the need for risk reduction strategies, staff support, and training to ensure staff wellbeing in stressful situations.
Field TS, Fouayzi H, Crawford S, et al. J Am Med Dir Assoc. 2021;Epub Apr 1.
Transitioning from hospital to nursing home (NH) can be a vulnerable time for patients. This study looked for potential associations between adverse events (AE) for NH residents following hospital discharge and NH facility characteristics (e.g., 5-star quality rating, ownership, bed size). Researchers found few associations with individual quality indicators and no association between the 5-star quality rating or composite quality score. Future research to reduce AEs during transition from hospital to NH should look beyond currently available quality measures.
Cataldo RRV, Manaças LAR, Figueira PHM, et al. J Oncol Pharm Pract. 2021;Epub Mar 30.
Clinical pharmacist involvement has improved medication safety in several clinical areas. Using the therapeutic outcome monitoring (TOM) method, pharmacists in this study identified 43 negative outcomes associated with oral chemotherapy medication and performed 81 pharmaceutical interventions. The TOM method increased patient safety by improving the use of medications.
Schneider J, Wirth A. Biomed Instrum Technol. 2021;55(1):21-28.
Cybersecurity risks in healthcare settings can threaten patient safety. This article outlines the value of a Clinical Director of Cybersecurity, representing a partnership between security-educated clinicians and security professionals. This individual would support development of an effective cybersecurity program through cyber awareness, hygiene (i.e., practices to reduce security risk), management, and cyber-incident response.
Wehkamp K, Kuhn E, Petzina R, et al. BMC Med Ethics. 2021;22(1):26.
Clinicians are often confronted by ethical issues during the delivery of care. The authors outline four categories of critical incidents relevant to biomedical ethics – (1) patient-related communication, (2) consent, autonomy, and patient interest, (3) conflicting economic and medical interests, and (4) staff communication and corporate culture. The authors suggest that integrating these dimensions into existing incident reporting system processes (e.g., training risk managers and nurses to identify ethical incidents, involving an ethnical committee or specialists for clinical ethical consultations) may increase ethical behavior, patient safety, and employee satisfaction.     
Weinger MB. BMJ Qual Saf. 2021;Epub Mar 25.
Checklists are widely used strategies for error reduction and improved communication. This editorial discusses the limitations of checklists for perioperative safety (i.e., when used in isolation or implemented incorrectly) and suggests that safety initiatives taking a systems-oriented approach and organizational buy-in can lead to both perioperative and general safety improvements.
Cifra CL, Custer JW, Singh H, et al. Pediatr Crit Care Med. 2021;Epub April 10.
Diagnostic errors continue to be a patient safety concern, including in pediatric critical care. This systematic review explored the prevalence, impact, and contributing factors to diagnostic errors in the pediatric intensive care unit (PICU). The most common diagnostic errors occurred in cardiovascular, infectious, congenital, and neurologic conditions; cognitive and systems factors were associated with diagnostic errors. Future research should focus on disease- and systems-level determinants. 
Upcoming Meeting/Conference

Armstrong Center for Patient Safety and Quality. September 29, 2021.

The Resilience in Stressful Events (RISE) program provides peer assistance for healthcare workers who experience psychological effects after involvement in stressful adverse care events. This two-part virtual session presents RISE implementation education and orientation for staff to respond when peer support is needed.

Kuhn CM, Newton RC, Damewood MD, et al, on behalf of the CLER Evaluation Committee, the CLER Operative and Procedural Subprotocol National Advisory Group, and the CLER Program. Chicago, IL: Accreditation Council for Graduate Medical Education; February 2021. ISBN: 9781945365386.

The teaching hospital environment can produce clinician behaviors and mindsets that persist throughout a medical career. This report from a clinical learning environment assessment program shares insights gathered during walking rounds specific to perioperative care and general medicine. The report concluded that residents did not actively report problems and rarely participated in event investigations.

Agency for Healthcare Research and Quality.

Safe diagnosis in medical offices is challenged by staff workload, communication, and poor information sharing. This survey supplement examines elements contributing to time availability, testing and referrals, and provider and staff communication. The set is to be used in conjunction with the Agency for Healthcare Research and Quality's Medical Office Survey on Patient Safety Culture (MOSOPS®). The supplemental item set was released in time for the upcoming data submission window for the MOSOPS (September 1 - October 20, 2021).

Famolaro T, Hare R, Thornton S, et al. Surveys on Patient Safety CultureTM (SOPSTM). Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0034.

A vibrant culture of safety is critical to achieving high reliability in health care. Ambulatory practices with weaker safety cultures can experience problems in teamwork, diagnosis, and staff turnover. The AHRQ Medical Office Survey on Patient Safety Culture was designed to evaluate safety culture in outpatient clinics. The 2020 comparative database report assessed 10 safety culture domains in 1,475 medical offices. Respondents reported effective patient follow-up practices and scored well on equitable care delivery. Many practices cited time pressure and workload as persistent challenges to safety hazards. Although the practices surveyed are not nationally representative, they do provide a comparative safety culture snapshot for industry assessment. A past WebM&M commentary discussed safety hazards associated with productivity pressures in health care.

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.