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May 19, 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

Cohen AJ, Lui H, Zheng M, et al. JAMA Netw Open. 2021;4(5):e217058.
While rare, surgical never events can have tragic consequences for patients including permanent harm and death. This study analyzed 142 surgical never events reported to the California Department of Public Health. Retained foreign objects were the most commonly reported never event (66.2%), followed by wrong site or wrong patient (15.5%), and surgical burns (7.7%). Recommended strategies to reduce and prevent never events include proper use of intraoperative checklists.
Rand S, Smith N, Jones K, et al. BMJ Open. 2021;11(3):e043206.
Care home settings, such as nursing homes or residential care homes, present unique challenges to patient safety. This systematic review identified several gaps in the available safety measures used for quality monitoring and improvement in older adult care homes, including patient experience (e.g., quality of life or other resident-reported indicators of safety), psychological harm related to the care home environment, abusive or neglectful practices, and the absence of processes for integrated learning.
Schnipper JL, Reyes Nieva H, Mallouk M, et al. BMJ Qual Saf. 2021;Epub May 1.
Medication reconciliation aims to prevent adverse events during transitions of care, but implementing effective interventions supporting medication reconciliation has proven challenging. Building upon lessons learned in the MARQUIS1 study, this pragmatic quality improvement study (MARQUIS2) implemented a refined toolkit including system-level and patient-level interventions as well as physician mentors providing remote coaching and in-person site visits. Across 17 hospital sites, the intervention was associated with a significant decrease in unintentional mediation discrepancies over time.
Kepner S, Jones RM. Patient Safety. 2021;3(2):6-21.
Acute healthcare facilities in Pennsylvania are required to report all events of harm or potential harm to the Pennsylvania Patient Safety Reporting System (PA-PSRS). Of all submitted events in 2020, 97% were from hospitals, and 97% were incidents; 3 percent were serious events. The most common event was Error Related to Procedure/Treatment/Test (32%). There was a 5.3% decrease from the prior year in the number of reported events, indicating the COVID-19 pandemic had an impact on reporting activity.
Chalmers K, Smith P, Garber J, et al. JAMA Netw Open. 2021;4(4):e218075.
Overtreatment and overuse of healthcare services have been identified as potential sources of patient harm. Using Medicare fee-for-services claims, this study sought to describe hospital characteristics associated with 12 low-value services. Results showed the highest levels of overuse were associated with nonteaching and for-profit hospitals, particularly in the American South. The authors suggest interventions to decrease overuse and overtreatment could be targeted based on hospital characteristics and region.
Li Q, Hu P, Kang H, et al. J Nutr Health Aging. 2020;25(4):492-500.
Missed and delayed diagnosis are a known cause of preventable adverse events. In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury (AKI). However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed AKI. Involvement of intensive care kidney specialists is recommended to increase diagnostic awareness.
Schnipper JL, Reyes Nieva H, Mallouk M, et al. BMJ Qual Saf. 2021;Epub May 1.
Medication reconciliation aims to prevent adverse events during transitions of care, but implementing effective interventions supporting medication reconciliation has proven challenging. Building upon lessons learned in the MARQUIS1 study, this pragmatic quality improvement study (MARQUIS2) implemented a refined toolkit including system-level and patient-level interventions as well as physician mentors providing remote coaching and in-person site visits. Across 17 hospital sites, the intervention was associated with a significant decrease in unintentional mediation discrepancies over time.
Hannum SM, Abebe E, Xiao Y, et al. Appl Ergon. 2020;91:103299.
Discharge can be a vulnerable time for patients, particularly older adults taking multiple medications. Through interviews with clinicians from 10 professional roles, researchers identified three key strategies to promote safe medication management at hospital discharge: (1) streamlining medication reconciliation across care settings, (2) building patient capacity and engagement, and (3) redesigning the transitional process. Aligning clinician and patient care transition goals using these three strategies may better prepare patients to safely self-manage their medications at home.   
Remtulla R, Hagana A, Houbby N, et al. BMC Health Serv Res. 2021;21(1):269.
Psychological safety can empower health care workers to voice concerns and offer suggestions in a collaborative way that contribute to effective care. Based on semi-structured interviews with primary care providers, the authors of this study discuss the influence of shared beliefs on psychological safety in primary care teams, as well as barriers (e.g., hierarchy, authoritarian leadership) and facilitators (e.g., inclusiveness) to psychological safety.
Olivarius‐McAllister J, Pandit M, Sykes A, et al. Anaesthesia. 2021;Epub May 1.
UK Regulators measure never events to assess hospital safety culture and dictate reimbursement. The authors suggest that regulators focus on reducing the national never event rate through shared learning and an integrated system-wide approach, rather than concentrating on underperforming, outlier hospitals where factors such as safety culture maybe contributing to increased rates of never events.
Harder VS, Plante TB, Koh I, et al. J Gen Intern Med. 2021;Epub May 6.
In an effort to reduce opioid overdose and adverse events, many states enacted policies limiting dose and duration of opioid prescriptions. This study analyzed the rates of opioid overdose and adverse effects in primary care patients before and after the implementation of prescribing policies in Vermont. While there was no change in opioid overdose rates following implementation, there was a 78% decrease in adverse effects rates, particularly among patients with chronic opioid prescriptions and opioid-naïve patients. Statewide policies limiting dose and duration of opioid prescriptions may have positive results among primary care patients.
Cohen AJ, Lui H, Zheng M, et al. JAMA Netw Open. 2021;4(5):e217058.
While rare, surgical never events can have tragic consequences for patients including permanent harm and death. This study analyzed 142 surgical never events reported to the California Department of Public Health. Retained foreign objects were the most commonly reported never event (66.2%), followed by wrong site or wrong patient (15.5%), and surgical burns (7.7%). Recommended strategies to reduce and prevent never events include proper use of intraoperative checklists.
Panda N, Sinyard RD, Henrich N, et al. J Patient Saf. 2021;17(4):256-263.
The COVID-19 pandemic has presented numerous challenges for the healthcare workforce, including redeploying personnel to different locations or retraining personnel for different tasks. Researchers interviewed hospital leaders from health systems in the United States, United Kingdom, New Zealand, Singapore and South Korea about redeployment of health care workers during the COVID-19 pandemic. The authors discuss effective practices and lessons learned preparing for and executing workforce redeployment, as well as concerns regarding redeployed personnel
Duhn L, Gumapac N, Medves J. Patient Exp J. 2021;8(1):59-68.
Patients are increasingly encouraged to actively participate in their own care as a method to increase safety. In this study of 28 hospitalized patients, most believed they could rely on their own knowledge and alertness to protect themselves from medical error and just over half indicated they “always” or “usually” check their medications. The authors recommend further research into patient involvement with prevention of medication errors and, more broadly, development and validation of an instrument to measure in-hospital patient safety.  
Ekkens CL, Gordon PA. Holist Nurs Pract. 2021;35(3):115-122.
Despite system-level interventions, medication administration errors (MAE) continue to occur. Nurses at an American hospital were trained in mindful thinking in an effort to reduce MAE. After three months, nurses who received the mindfulness training had fewer medication errors, and less severe errors, than nurses who did not receive the training. Mindful thinking was effective at reducing medication administration errors and the authors recommend trainings be part of nurses’ orientation and continuing education.
Rivera-Chiauzzi E, Finney RE, Riggan KA, et al. J Patient Saf. 2021;Epub Apr 20.
Using a validated tool, this study found that nearly 19% of clinical and nonclinical healthcare workers in obstetrics and gynecology settings reported a second victim experience within the last 12 months.  Survey respondents who identified as a second victim reported significantly more psychological and physical distress, perceived inadequacy of institutional support, decreased professional self-efficacy, and increased turnover intentions. Prior research reported similar findings among nurses in obstetrics and gynecology.
No results.
Mcmullan RD, Urwin R, Gates PJ, et al. Int J Qual Health Care. 2021;33(2):mzab068.
Distractions in the operating room are common and can lead to errors. This systematic review including 27 studies found that distractions, interruptions, and disruptions in the operating room are associated with a range of negative outcomes. These include longer operative duration, impaired team performance, self-reported errors by colleagues, surgical errors, surgical site infections, and fewer patient safety checks.
Rand S, Smith N, Jones K, et al. BMJ Open. 2021;11(3):e043206.
Care home settings, such as nursing homes or residential care homes, present unique challenges to patient safety. This systematic review identified several gaps in the available safety measures used for quality monitoring and improvement in older adult care homes, including patient experience (e.g., quality of life or other resident-reported indicators of safety), psychological harm related to the care home environment, abusive or neglectful practices, and the absence of processes for integrated learning.
No results.

Eldeib D. ProPublica. May 4, 2021.

Concerns continue to emerge regarding the effect of the COVID-19 pandemic has had on the timely diagnosis of cancer. This story highlights the impact of patient inability or unwillingness to schedule annual screenings, physician visits and treatment of chronic conditions and primary contributors to the problem.

Agency for Healthcare Research and Quality. May 3, 2021. Fed Register. 2021;86(83):23366-23369.

This notice announces a call for comments on an information collection project drawing from the Comprehensive Unit-based Safety Program (CUSP). This project will support the implementation of targeted hospital-acquired infection improvement initiatives in intensive care units, long term care and surgical environments to reduce the prevalence of methicillin-resistant Staphylococcus aureus (MRSA). The process for submitting comments is now closed.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; May 4. 2021.

Anesthesia medications can be high risk should dosing errors occur. This company announcement reports a recall of two lots of anesthetics that have been mislabeled to mitigate the potential for patient harm due to misinformation.

ISMP Medication Safety Alert! Acute Care Edition. May 6, 2021;26(9):1-4.

Look-alike labeling is a known contributor to medication errors. This article summarizes common factors resulting in packaging and labeling concerns. Recommendations for improvement include partnerships with industry regarding the use of risk management practices to improve the accuracy of labeling prior to product launch.

National Academies of Sciences, Engineering, and Medicine. Washington DC:  National Academies Press; 2021. ISBN: 9780309685061. 

Health care system safety and effectiveness requires an engaged and empowered nursing workforce. This report builds on the foundation of nursing as a core care contributor. It shares a framework positioning nurses to improve equity, reduce disparities and support family-centered care in the future through education, healthy work environments and enhanced professional autonomy.

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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