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May 26, 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

Haveland S, Islam S. Telemed J E Health. 2021;Epub May 7.
At the start of the COVID-19 pandemic, many health systems and providers pivoted from in-person services to telehealth visits. Authors conducted a review of 21 studies evaluating the safety of telehealth visits. Three major themes emerged (telehealth experience, outcomes, and risks) along with several subthemes. Overall, the results suggest patients and clinicians have positive experiences and comparable health outcomes.
O'Donovan R, De Brún A, McAuliffe E. Front Psychol. 2021;12:626689.
Organizational cultures that encourage psychological safety can increase safe healthcare practices. Thirty-four healthcare professionals were interviewed about their experiences with psychological safety and speaking up behaviors. Researchers identified four themes influencing psychological safety and individual- and team-level inhibiting and motivating dynamics, including interpersonal, leadership, and hierarchy dynamics. Several intervention components to encourage psychological safety are reviewed, including inclusive behaviors, discrimination training, shared mental models, and conflict resolution. 
Patrick NA, Johnson TS. Nurs Womens Health. 2021;25(3):212-220.
Improving maternal safety is a patient safety priority in the United States. This article reviews the unique impact of the COVID-19 pandemic on maternal and newborn populations, such as implications for maternity care, maternal-newborn separation, and universal testing. Based on experiences at a maternal-fetal medicine clinic in a tertiary care center in Wisconsin, the authors describe practice changes to maintain safety, minimize COVID-19 transmission, and optimize patient safety during the pandemic.
Aho-Glele U, Pomey M-P, Gomes de Sousa MR, et al. Patient Exp J. 2021;8(1):45-58.
Patient engagement is an important strategy to improve quality and safety of care. This article describes the development of a tool for managers to assess patient engagement strategies within their health system. The tool contains four sections: (1) describing the healthcare organization; (2) gathering general information on their current patient engagement strategies; (3) assessing patient engagement strategies; and (4) describing their involvement in patient safety committees. The tool is intended to assess the health system’s integration of patient engagement for patient safety and to track changes over time.
Sundberg F, Fridh I, Lindahl B, et al. Nurs Crit Care. 2020;26(2):86-93.
The design of health care environments can affect safety. Conducted in one intensive care unit (ICU) in Sweden, this study did not identify any difference in adverse events such as healthcare-acquired infections or unplanned reintubation occurring in regular ICU rooms, as compared to refurbished rooms (e.g., acoustic panels, cyclic lighting, accessible patio).
Zimmer M, Czarniecki DM, Sahm S. PLoS ONE. 2021;16(5):e0250932.
Inadequate team communication is a marker of poor safety culture and can threaten patient safety. This survey of 714 medical and non-medical emergency medical services (EMS) employees in Germany found nearly three-quarters of respondents had been involved in a patient harm incident and that deficits in team communication were a primary contributor.  
Simon GE, Stewart CC, Gary MC, et al. Jt Comm J Qual Patient Saf. 2021;47(7):452-457.
The COVID-19 pandemic expanded the use of telehealth and virtual care. This article describes one health system’s experience adapting suicide risk assessments for virtual visits and how the use of electronic health record patient portal messaging can facilitate systematic identification and assessment of suicide risk among patients receiving virtual mental health care.
O'Donovan R, De Brún A, McAuliffe E. Front Psychol. 2021;12:626689.
Organizational cultures that encourage psychological safety can increase safe healthcare practices. Thirty-four healthcare professionals were interviewed about their experiences with psychological safety and speaking up behaviors. Researchers identified four themes influencing psychological safety and individual- and team-level inhibiting and motivating dynamics, including interpersonal, leadership, and hierarchy dynamics. Several intervention components to encourage psychological safety are reviewed, including inclusive behaviors, discrimination training, shared mental models, and conflict resolution. 
Manias E, Bucknall T, Woodward-Kron R, et al. Int J Environ Res Public Health. 2021;18(8):3925.
Interprofessional communication is critical to safe medication management during transitions of care. Researchers conducted this ethnographic study to explore inter- and intra-professional communications during older adults’ transitions of care. Communication was influenced by the transferring setting, receiving setting, and ‘real-time’ communication. Lack of, or poor, communication impacted medication safety; researchers recommend more proactive communication and involvement of the pharmacist.
Uitvlugt EB, Janssen MJA, Siegert CEH, et al. Front Pharmacol. 2021;12:567424.
Identifying and reducing potentially preventable readmissions is a patient safety priority. This study found that 16% of readmissions at one teaching hospital in the Netherlands were medication-related; of those, 40% were considered potentially preventable. Preventable readmissions were attributed to prescribing errors, non-adherence, and handoff or transition errors.

Masonbrink AR, Harris M, Hall M, et al. Hosp Pediatr. 2021;11(6):e95-e100.

This study analyzed Pediatric Quality Indicators (PDIs) to compare pediatric safety events before and during the COVID-19 pandemic. Results indicate an increased risk for overall PDIs, but only postoperative sepsis showed increased odds. Given the continuing nature of the COVID-19 pandemic, and risk of future pandemics, more efforts are needed to ensure the safety of pediatric patients.
Serou N, Husband AK, Forrest SP, et al. J Patient Saf. 2021;17(5):335-340.
Clinicians involved in a medical error may experience emotional distress, shame, and self-doubt. This qualitative study with medical and non-medical operating room staff at five hospitals in the United Kingdom explored support received after involvement in a patient safety incident. Participants were most likely to receive support from their peers after a patient safety incident, but highlighted a lack of institutional-level emotional and professional support and the need to cultivate an organizational culture where seeking support is not perceived as a sign of weakness.
Scantlebury A, Sheard L, Fedell C, et al. Digit Health. 2021;7:205520762110100.
Electronic health record (EHR) downtime can disrupt patient care and increase risk for medical errors. Semi-structured interviews with healthcare staff and leadership at one large hospital in England illustrate the negative consequences of a three-week downtime of an electronic pathology system on patient experience and safety. The authors propose recommendations for hospitals to consider when preparing for potential technology downtimes.
Barwise A, Leppin A, Dong Y, et al. J Patient Saf. 2021;17(4):239-248.
Diagnostic errors and delays continue to be a widespread patient safety concern in hospitalized patients. Researchers conducted focus groups with key clinician stakeholders to determine factors that contribute to diagnostic error and delay. Clinicians indicated that organizational, interactional, clinician, and patient factors all interact to cause errors and delays. These diverse factors must be considered when implementing interventions to reduce diagnostic errors and delays.
Bilimoria KY, Barnard C. JAMA. 2021;325(21):2151-2152.
The Hospital Star Rating system was implemented in 2016 to aid patients in identifying safe, high-quality hospitals. The system has evolved over time to address applicability concerns. This commentary highlights changes in the latest reiteration of the program and discusses challenges in its use.
Patrick NA, Johnson TS. Nurs Womens Health. 2021;25(3):212-220.
Improving maternal safety is a patient safety priority in the United States. This article reviews the unique impact of the COVID-19 pandemic on maternal and newborn populations, such as implications for maternity care, maternal-newborn separation, and universal testing. Based on experiences at a maternal-fetal medicine clinic in a tertiary care center in Wisconsin, the authors describe practice changes to maintain safety, minimize COVID-19 transmission, and optimize patient safety during the pandemic.
Brockett-Walker C, Lall M, Evans DD, et al. Adv Emerg Nurs J. 2021;43(2):89-101.
This review critiques a 2016 article (link below) which found unconscious, implicit bias can negatively impact patient care when emergency department providers are under increased cognitive stress. The authors propose strategies for educators and institutions to combat implicit bias including self-awareness, stress reduction, and respectful communication.
Farhat A, Al‐Hajje A, Csajka C, et al. J Clin Pharm Ther. 2021;Epub Mar 26.
Several tools have been developed to reduce potentially inappropriate prescribing. This study explored the economic and clinical impacts of two tools, STOPP/START and FORTA (Fit fOR The Aged list). Randomized controlled trials (RCTs) using those tools demonstrated significant clinical and economic impact in geriatric and internal medicine. Due to the low number of RCT studies evaluating these tools, additional studies are warranted.
Haveland S, Islam S. Telemed J E Health. 2021;Epub May 7.
At the start of the COVID-19 pandemic, many health systems and providers pivoted from in-person services to telehealth visits. Authors conducted a review of 21 studies evaluating the safety of telehealth visits. Three major themes emerged (telehealth experience, outcomes, and risks) along with several subthemes. Overall, the results suggest patients and clinicians have positive experiences and comparable health outcomes.
Meeting/Conference Proceedings

Patient Safety Movement Foundation. 2021. 

The Communication and Optimal Resolution (CANDOR) model was designed to support early error disclosure with patients and families after mistakes in care occur. This three-part webinar series introduced the CANDOR process, discussed CANDOR implementation, outlined the importance of organizational readiness assessment for the program, and described actions to sustain CANDOR after it has launched. Speakers include Dr. Timothy McDonald, the originator of the model.

Society to Improve Diagnosis in Medicine. June 3, 2021.

The use of telemedicine has expanded during the COVID-19 pandemic into the mental health and diagnostic realms. This session explored how the practice of telediagnosis has emerged and share concerns about its safety and quality. Dr. Mark Graber is a featured speaker.

Weiser S. The New Yorker and Retro Report; 2021.

Disparities in maternal care have become apparent as a public health concern during the COVID-19 pandemic. This short film spotlights inequities and biases that Black mothers face, that reduce the safety of their care. Midwives are offered as a strategy for improving the safety of maternal care in this patient population.

Washington DC:  Department of Veterans Affairs. Office of Inspector General; May 11, 2021. Report No. 20-03593-140.

Health care system failures can enable unrecognized, persistent criminal behavior. This report examines conditions contributing to a serial murder case including weaknesses in mortality data analysis, clinical documentation review, patient safety incident reporting, medication security processes, and safety culture.

Institute for Safe Medication Practices

The perioperative setting is a high-risk area for medication errors, should they occur. This assessment provides hospitals and outpatient surgical providers a tool to examine their medication use processes and share data nationwide for comparison. Organizational participation can identify strengths and gaps in their systems to design opportunities that prevent patient harm. The deadline for submitting data is December 10, 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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