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May 5, 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

Barbash IJ, Davis BS, Yabes JG, et al. Ann Intern Med. 2021;174(7):927-935.
Starting in 2015, the Centers for Medicare & Medicaid Services has required hospitals to report adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). This study examined sepsis patient encounters at one health system two years before and two years after SEP-1 implementation. Results indicate variable changes in process measures but no improvement in clinical outcomes. The authors suggest revising the measure with more flexible guidelines that allow clinician discretion may improve patient outcomes.
Fuller G, Pandor A, Essat M, et al. J Trauma Acute Care Surg. 2021;90(2):403-412.
Prehospital triage tools are used to differentiate between patients who need emergency care at a major trauma center (MTC) and those that may receive adequate care at a non-MTC.  Accurate triage tools are necessary to ensure that patients are not over- or undertriaged. This review found high variability in sensitivity and specificity across geriatric triage tools indicating some patients may not be receiving the specialized trauma care they need. The authors highlight several future research targets including development of relevant reference standards and balancing the risk between over- and undertriage.
Morgan DJ, Pineles L, Owczarzak J, et al. JAMA Intern Med. 2021;Epub Apr 5.
Overdiagnosis is an emerging safety concern due to its potential to result in physical, financial, and emotional harm. Researchers surveyed 533 primary care practitioners (physicians, nurse practitioners, and physician assistants) and asked them to estimate the probability of disease for common conditions (pneumonia, cardiac ischemia, breast cancer screening, and urinary tract infection) and the association of positive and negative test results with disease probability. Findings indicate that significant overestimation of disease among all participating practitioners – likely due to overestimates of pretest probability – may contribute to overdiagnosis and overuse.
Morgan DJ, Pineles L, Owczarzak J, et al. JAMA Intern Med. 2021;Epub Apr 5.
Overdiagnosis is an emerging safety concern due to its potential to result in physical, financial, and emotional harm. Researchers surveyed 533 primary care practitioners (physicians, nurse practitioners, and physician assistants) and asked them to estimate the probability of disease for common conditions (pneumonia, cardiac ischemia, breast cancer screening, and urinary tract infection) and the association of positive and negative test results with disease probability. Findings indicate that significant overestimation of disease among all participating practitioners – likely due to overestimates of pretest probability – may contribute to overdiagnosis and overuse.
Schulz-Moore JS, Bismark MM, Jenkinson C, et al. Jt Comm J Qual Patient Saf. 2021;47(6):376-384.
Error disclosure is critical to improving communication and patient safety. This article describes the development and pilot testing of the Medical Injury Reconciliation Experiences Survey (MIRES). The final 40-item survey addresses patient and/or family perceptions of communications with healthcare providers after the injury, perceptions of remedial gestures, overall satisfaction with the reconciliation process, the nature and impacts of the injury, and patient characteristics.
Sturman N, Parker M, Jorm C. Adv Health Sci Educ Theory Pract. 2021;26(1):297-311.
Balancing adequate supervision and autonomy for clinical trainees is an ongoing challenge. This study used qualitative methods to explore how general practice supervisors approach trainee help-seeking and in-consultation supervision. Findings highlight the role of entrustment processes between supervisor, trainee, and patient, and areas for improvement in the oversight of trainee consultations in general practice. A November 2018 Spotlight Case discusses the factors that determine entrustment decisions for trainees.
Denning M, Goh ET, Tan B, et al. PLoS One. 2021;16(4):e0238666.
This cross-sectional study conducted from March to June 2020 measured anxiety, depression, and burnout in clinicians working in the United Kingdom, Poland, and Singapore. Approximately 70% of respondents reported feeling anxious, depressed and/or burnt out. Burnout was significantly inversely correlated with being tested for COVID-19 and perceiving high levels of safety. These findings highlight the importance of supporting staff well-being and proactive COVID-19 testing.
Kurteva S, Habib B, Moraga T, et al. Value Health. 2021;24(2):147-157.
Harms related to prescription opioid use are an ongoing patient safety challenge. Based on data from one hospital between 2014 and 2016, this cohort study found that nearly 50% of hospitalized patients were discharged with an opioid prescription, and 80% of those prescriptions were among patients discharged from a surgical unit. Opioid-related medication errors were more common in handwritten discharge prescriptions compared to electronic prescriptions; electronic prescriptions were associated with a 69% lower risk of opioid-related medication errors.
Adie K, Fois RA, McLachlan AJ, et al. Eur J Clin Pharmacol. 2021;Epub Mar 2.
Community pharmacists play an important role in patient safety. In this longitudinal study, community pharmacists reported 1,013 medication incidents, mainly at the prescribing and dispensing stages. Recommended prevention strategies included improved patient safety culture, adherence to organizational policies and procedures, and healthcare provider education.
Hahn EE, Munoz-Plaza CE, Lee EA, et al. J Gen Intern Med. 2021;Epub Jan 21.
Older adults taking potentially inappropriate medications (PIMs) are at increased risk of adverse events including falls. Patients and primary care providers described their knowledge and awareness of risk of falls related to PIMs, deprescribing experiences, and barriers and facilitators to deprescribing. Patients reported lack of understanding of the reason for deprescribing, and providers reported concerns over patient resistance, even among patients with falls. Clinician training strategies, patient education, and increased trust between providers and patients could increase deprescribing, thereby reducing risk of falls. 
Gordo C, Núñez‐Córdoba JM, Mateo R. J Adv Nurs. 2021;77(7):3168-3175.
This cross-sectional, mixed method study sought to prioritize common root causes for medication errors. Analysis showed the main root cause was lack of adherence to safety protocols, followed by identification errors and fragile and polymedicated patients. The authors propose artificial intelligence (AI) as a potential strategy to improve compliance with protocols and patient identification.
Barbash IJ, Davis BS, Yabes JG, et al. Ann Intern Med. 2021;174(7):927-935.
Starting in 2015, the Centers for Medicare & Medicaid Services has required hospitals to report adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). This study examined sepsis patient encounters at one health system two years before and two years after SEP-1 implementation. Results indicate variable changes in process measures but no improvement in clinical outcomes. The authors suggest revising the measure with more flexible guidelines that allow clinician discretion may improve patient outcomes.
Sedlár M. Int J Occup Saf Ergon. 2021;Epub Mar 19.
Stress and fatigue experienced by healthcare workers can threaten patient safety. This survey of 131 emergency medical services (EMS) crew members identified a relationship between work-related factors (e.g., stress, fatigue), unsafe behavior, and safety incident involvement. Reducing stress and fatigue and improving cognitive skills, including situation awareness, can improve compliance with safe behaviors.
Zhang T, Mosier J, Subbian V. JMIR Hum Factors. 2021;8(2):e24860.
The increased use of telehealth during the COVID-19 pandemic has not been without challenges. This article uses the Systems Engineering Initiative for Patient Safety (SEIPS) model to assess barriers related to telehealth implementation during the pandemic and the impact on patients, providers, technology, care processes, organizations, and the environment.
Isherwood P, Waterson P. J Patient Saf Risk Manag. 2021;26(2):64-73.
Investigating adverse events and identifying contributing factors is essential to organizational learning and improving patient safety. The authors of this article use three different methodologies – root cause analysis (RCA), human factors analysis classification system (HFACS), and AcciMap (which places emphasis on multiple levels of decision making important to risk management) – to analyze one near miss incident and illustrate how different methodologies generate different systems-level recommendations.
Fuller G, Pandor A, Essat M, et al. J Trauma Acute Care Surg. 2021;90(2):403-412.
Prehospital triage tools are used to differentiate between patients who need emergency care at a major trauma center (MTC) and those that may receive adequate care at a non-MTC.  Accurate triage tools are necessary to ensure that patients are not over- or undertriaged. This review found high variability in sensitivity and specificity across geriatric triage tools indicating some patients may not be receiving the specialized trauma care they need. The authors highlight several future research targets including development of relevant reference standards and balancing the risk between over- and undertriage.
Cerqueira O, Gill M, Swar B, et al. BMJ Qual Saf. 2021;Epub Apr 21.
Computerized prescriber order entry (CPOE) systems embedded in electronic health systems alert clinicians to potential safety concerns such as drug-drug interactions or medication dosage errors. Results of this review indicate that alerts influenced prescriber behavior in most of the included studies. However, it is unclear whether these behavioral changes improve patient safety outcomes. Recommendations for future research include randomized controlled trials to determine which alerts maximize patient safety, while minimizing prescribers’ alert fatigue.
No results.

Parry C. The Pharmaceutical JournalApril 22 2021.

Weight-based prescribing in children harbors challenges to accurate medication dosing. This story discusses an examination of factors contributing to ten-fold medication errors in pediatric care. The author summarizes an ongoing investigation which has identified polypharmacy and information system weaknesses as being among the contributors to the problem.

Bebinger M. WBUR and Kaiser Health News. April 27, 2021.

Non-English-speaking patients experience barriers to safely navigating the American healthcare system. This story discusses the impact that language and disparities had on care during the pandemic at one health system, and shares outreach communication and translation strategies to improve care safety.

Kaplan A. NBC News. April 21, 2021.

Pharmacies are high-pressure environments generating conditions that undermine safety. This story highlights working conditions in chain pharmacies that cause concerns for pharmacists in their ability to prepare and dispense medications safely due to lack of appropriate staffing and time to do their jobs.

This Month’s WebM&Ms

WebM&M Cases
Jeremiah Duby, PharmD, Kendra Schomer, PharmD, Victoria Oyewole, PharmD, Delia Christian, RN, BSN, CNRN, and Sierra Young, PharmD |
A 65-year-old man with a history of type 2 diabetes mellitus, hypertension, and coronary artery disease was transferred from a Level III trauma center to a Level I trauma center with lower extremity paralysis after a ground level fall complicated by a 9-cm abdominal aortic aneurysm and cervical spinal cord injury. Post transfer, the patient was noted to have rapidly progressive ascending paralysis. Magnetic resonance imaging (MRI) revealed severe spinal stenosis involving C3-4 and post-traumatic cord edema/contusion involving C6-7. A continuous intravenous (IV) infusion of norepinephrine was initiated to maintain adequate spinal cord perfusion, with a target mean arterial pressure goal of greater than 85 mmHg. Unfortunately, norepinephrine was incorrectly programmed into the infusion pump for a weight-based dose of 0.5 mcg/kg/min rather than the ordered dose of 0.5 mcg/min, resulting in a dose that was 70 times greater than intended. The patient experienced bradycardia and cardiac arrest and subsequently died.
WebM&M Cases
Spotlight Case
Sarina Fazio, PhD, RN, Emma Blackmon, PhD, RN, Amy Doroy, PhD, RN, Ai Nhat Vu and Paul MacDowell, PharmD. |
A 64-year-old woman was admitted to the hospital for aortic valve replacement and aortic aneurysm repair. Following surgery, she became hypotensive and was given intravenous fluid boluses and vasopressor support with norepinephrine. On postoperative day 2, a fluid bolus was ordered; however, the fluid bag was attached to the IV line that had the vasopressor at a Y-site and the bolus was initiated. The error was recognized after 15 minutes of infusion, but the patient had ongoing hypotension following the inadvertent bolus. The commentary summarizes the common errors associated with administration of multiple intravenous infusions in intensive care settings and gives recommendations for reducing errors associated with co-administration of infusions.
WebM&M Cases
Kelly Haas, MD, and Andrew Lee, PharmD |
A 4-year-old (former 33-week premature) boy with a complex medical history including gastroschisis and subsequent volvulus in infancy resulting in short bowel syndrome, central venous catheter placement, and home parenteral nutrition (PN) dependence was admitted with hyponatremia. A pharmacist from the home infusion pharmacy notified the physician that an error in home PN mixing had been identified; a new file had been created for this chronic PN patient by the home infusion pharmacy and the PN formula in this file was transcribed erroneously without sodium acetate. This error resulted in only 20% of the patient’s prescribed sodium being mixed into the home PN solution for several weeks, resulting in hyponatremia and unnecessary hospital admission. The commentary highlights the importance of collaboration between clinicians and patients’ families for successful home PN and the roles of communication process maps, standardizing PN compounding, and order verification in reducing the risk of medication error.

This Month’s Perspectives

Chris Cebollero
Interview
Chris Cebollero, BS, CCEMT-P, is the President and CEO of Cebollero & Associates Consulting Group. He has served as a paramedic for over 20 years, and in his last operational role he was the Chief of EMS at Christian Hospital in North St. Louis. We spoke with him about the status of safety culture in EMS and challenge associated with safety event reporting.
Perspectives on Safety
This piece discusses Just Culture in EMS, where variation exists across systems, and challenges and opportunities to enhancing safety event reporting. 
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