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May 12, 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

Jungo KT, Streit S, Lauffenburger JC. BMC Geriatr. 2021;21(1):163.
The purpose of this retrospective cohort study of older adults with polypharmacy and multimorbidity was to identify patient characteristics associated with new prescriptions for potentially inappropriate medications (PIMs). Patients who are male, 85 years and older, diagnosed with heart disease, and have an increased number of ambulatory visits were most at risk for being newly prescribed PIMs. The authors recommend these characteristics be considered when developing interventions to reduce PIMs in the geriatric population. 
Park Y, Hu J, Singh M, et al. JAMA Netw Open. 2021;4(4):e213909.
Machine learning uses data and statistical methods to enhance risk prediction models and it has been promoted as a tool to improve healthcare safety. Using Medicaid claims data for a large cohort of White and Black pregnant females, this study evaluated approaches to reduce bias in clinical prediction algorithms for postpartum depression and mental health service utilization. The researchers found that a reweighing method in machine learning models was associated with a greater reduction in bias than excluding race from the prediction models. The authors suggest further examination of potentially biased data informing clinical prediction models and consideration of other methods to mitigate bias.
Reece JC, Neal EFG, Nguyen P, et al. BMC Cancer. 2021;21(1):373.
Lack of timely follow-up of test results is an ongoing patient safety problem in primary care and can lead to missed or delayed diagnoses. This systematic review concluded that follow-up of abnormal mammograms in primary care is suboptimal. Findings from included studies indicate that ethnic minorities and women with lower educational attainment were more likely to have inadequate follow-up. Factors influencing follow-up include physician-patient miscommunication, alert fatigue, difficulty obtaining test results or patient records, and logistical barriers. The authors suggest adopting interventions focused on mitigating factors that negatively impact follow-up, such as patient navigation and case management.
Longhini J, Papastavrou E, Efstathiou G, et al. J Nurs Manag. 2021;29(3):572-583.
This international qualitative study explored strategies employed by nurse managers and directors to prevent missed nursing care. Most strategies, including staffing ratios, communication, and empowering nurse leaders, required complex interventions at the system level, indicating missed nursing care is not merely a nursing issue. Nurse managers play a key role in implementing strategies at the nursing and hospital level.
Sharp R, Turner L, Altschwager J, et al. J Clin Nurs. 2021;Epub Mar 4.
Safety in home health care delivery is receiving increasing attention. This retrospective cohort study found that patients with medically stable, chronic conditions undergoing blood transfusion in a home setting provided by a nurse-led service experienced low rates of adverse events.
Park Y, Hu J, Singh M, et al. JAMA Netw Open. 2021;4(4):e213909.
Machine learning uses data and statistical methods to enhance risk prediction models and it has been promoted as a tool to improve healthcare safety. Using Medicaid claims data for a large cohort of White and Black pregnant females, this study evaluated approaches to reduce bias in clinical prediction algorithms for postpartum depression and mental health service utilization. The researchers found that a reweighing method in machine learning models was associated with a greater reduction in bias than excluding race from the prediction models. The authors suggest further examination of potentially biased data informing clinical prediction models and consideration of other methods to mitigate bias.
Pruitt ZM, Howe JL, Hettinger AZ, et al. J Patient Saf. 2021;Epub Apr 20.
Electronic health record (EHR) usability can affect clinicians’ ability to provide safe patient care. Thematic analysis of interviews with emergency medicine physicians reveal that the most common perceived usability strength was visual display of the EHR system, and the most common shortcoming was lack of workflow support (e.g., a workflow mismatch between the EHR system and how clinicians use the system to accomplish tasks).
Jungo KT, Streit S, Lauffenburger JC. BMC Geriatr. 2021;21(1):163.
The purpose of this retrospective cohort study of older adults with polypharmacy and multimorbidity was to identify patient characteristics associated with new prescriptions for potentially inappropriate medications (PIMs). Patients who are male, 85 years and older, diagnosed with heart disease, and have an increased number of ambulatory visits were most at risk for being newly prescribed PIMs. The authors recommend these characteristics be considered when developing interventions to reduce PIMs in the geriatric population. 
Velmahos CS, Kokoroskos N, Tarabanis C, et al. World J Surg. 2021;45(3):690-696.
The authors retrospectively reviewed records for 150 patients undergoing emergency surgery who experienced a preventable complication and/or death. The most common preventable complication was surgical site infections. The majority of complications were attributed to personal performance (technical or judgement issues) and a small proportion (3%) were attributed to systemic issues, such as poor communication or inadequate protocols.
Horberg MA, Nassery N, Rubenstein KB, et al. Diagnosis (Berl). 2021;Epub Apr 25.
Missed or delayed diagnosis of sepsis can lead to serious patient harm. This study used a Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) “look-forward” analysis to measure potential misdiagnosis of sepsis in patients discharged from the emergency department (ED) with treat-and-release fluid and electrolyte disorders (FED) or altered mental status (AMS). FED and AMS were associated with a spike in sepsis hospitalizations in the 7-day period following the ED visit. The authors suggest SPADE could be used to compare sepsis diagnostic performance across institutions and regions; develop interventions for targeted subgroups; and update early warning systems for sepsis diagnosis.
Lurvey LD, Fassett MJ, Kanter MH. Jt Comm J Qual Patient Saf. 2021;47(5):288-295.
High reliability organizations encourage staff to self-report errors and hazards for comprehensive review and improvement. Three hospitals in one health system implemented a voluntary error reporting system for clinicians to report their own and others’ clinical errors. Although only 5% of reported errors were physician self-reports, there were still benefits: it captured novel errors, provided a safe space to report those errors, and encouraged secondary insights into causes of the errors.
Longhini J, Papastavrou E, Efstathiou G, et al. J Nurs Manag. 2021;29(3):572-583.
This international qualitative study explored strategies employed by nurse managers and directors to prevent missed nursing care. Most strategies, including staffing ratios, communication, and empowering nurse leaders, required complex interventions at the system level, indicating missed nursing care is not merely a nursing issue. Nurse managers play a key role in implementing strategies at the nursing and hospital level.
Sands K, Blanchard J, Grubbs K, et al. Jt Comm J Qual Patient Saf. 2021;47(5):327-332.
This article describes the development of the Universal Protection Framework, which builds upon traditional infection prevention practices and consists of four domains (infection prevention, access control, distancing, and patient flow) supported by communication and education. The framework was implemented in one large health system with high levels of compliance, particularly for handling of personal protective equipment (PPE), cohorting of COVID-19 patients, facility access controls and employee exposure monitoring.
Zimolzak AJ, Shahid U, Giardina TD, et al. J Gen Intern Med. 2021;Epub Apr 29.
Inadequate follow-up of diagnostic testing can lead to missed or delayed diagnoses. Based on interviews with healthcare workers at Veterans Affairs (VA) facilities across the United States, this qualitative study identified factors contributing to lack of timely follow-up of abnormal test results. The most commonly cited factors included trainee/resident involvement, absence of a process to address  incidental findings on imaging, lack of standardized electronic health records (EHR) and related tracking systems, and lack of updated patient and provider contact information. The authors summarize participant recommendations to reduce missed test results.
Adelman JS, Gandhi TK. J Patient Saf. 2021;17(4):331-333.
The full impact of the COVID-19 pandemic on patient safety in the healthcare system is still unknown. New patient safety concerns have been introduced, and existing concerns have been exacerbated. The authors suggest several high reliability strategies to prevent and learn from patient safety hazards, including transparency, a culture of safety, and continuous analysis of errors.
Brown NJ, Wilson B, Szabadi S, et al. Patient Saf Surg. 2021;15(1):19.
At the start of the COVID-19 pandemic, many elective surgical procedures were canceled or postponed due to limited resources (e.g., personal protective equipment, diagnostic tests, redeployment of healthcare personnel). This commentary discusses the implications of rationed non-urgent surgical care within the context of medical ethics: beneficence, non-maleficence, justice, and autonomy. The authors developed an algorithm to guide surgical teams through the decision-making process of delaying non-urgent surgical procedures, if necessary, in the future. 
Shahian DM. BMJ Qual Saf. 2021;30(10):769-774.
The I-PASS structured handoff tool aims to improve communication during patient transfers and reduce errors and preventable adverse events. This editorial summarizes evidence supporting I-PASS implementation and the challenge of rigorously assessing the association between handoffs and adverse events, medical errors, and other clinical outcomes.
Fencl JL, Willoughby C, Jackson K. AORN J. 2021;113(4):329-336.
A just culture balances organizational and individual accountability when a medical error occurs. In a just culture, staff are more likely to report potential patient safety concerns. This commentary defines just culture, describes the critical elements, and provides tools and resources to implement a just culture in the perioperative setting that may increase staff and patient safety.  
Reece JC, Neal EFG, Nguyen P, et al. BMC Cancer. 2021;21(1):373.
Lack of timely follow-up of test results is an ongoing patient safety problem in primary care and can lead to missed or delayed diagnoses. This systematic review concluded that follow-up of abnormal mammograms in primary care is suboptimal. Findings from included studies indicate that ethnic minorities and women with lower educational attainment were more likely to have inadequate follow-up. Factors influencing follow-up include physician-patient miscommunication, alert fatigue, difficulty obtaining test results or patient records, and logistical barriers. The authors suggest adopting interventions focused on mitigating factors that negatively impact follow-up, such as patient navigation and case management.

Agency for Healthcare Research and Quality. June 2, 2021.

Measuring and improving safety culture are essential patient safety activities. This webinar introduced the Agency for Healthcare Research and Quality Medical Office Survey supplemental items focusing on diagnostic safety and presenters shared results from a pilot test.

ISMP Medication Safety Alert! Acute Care Edition. April 22, 2021.26(8):1-5.

Process change can introduce opportunities for error into established practice. This article builds on results of an earlier survey to expand the record on the types of COVID vaccine errors such as wrong patient age, dilution problems, and vaccine card confusion.

National Academies of Sciences, Engineering, and Medicine 2021. Washington, DC: The National Academies Press.

Primary care is the starting point for safe, equitable health care. This report outlines a system-focused implementation framework to enhance person-centered, accessible primary care. The approach aims to a focus on generating accountability through payment reform, multi-disciplinary team development, workforce support, and digital health utilization.
Special or Theme Issue

Acad Med. 2021;96(5): 611-769; e14-e21

Medical training is a demanding experience that impacts a learner’s ability to provide safe care, cope, and remain healthy. This issue covers a range of topics exploring the mental health consequences of residency, factors influencing well-being, and approaches to help individuals successfully navigate the stress of residency.

Washington DC: National Academies of Sciences, Engineering, and Medicine; 2021. ISBN: 9780309462808.

The Patient Safety and Quality Improvement Act of 2005 requires the Secretary of the U.S. Department of Health and Human Services (HHS), in consultation with the Director of the Agency for Healthcare Research and Quality, to prepare a report for Congress on effective strategies for reducing medical errors and increasing patient safety and on measures to encourage the appropriate use of such strategies.  The Act also requires that a draft of the report be made available for public comment and review by the Institute of Medicine (now the National Academy of Medicine (NAM)).  This publication reflects NAM’s review of the draft report.  HHS is in the process of preparing a final report due to Congress in December 2021.

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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