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June 2, 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

McHugh MD, Aiken LH, Sloane DM, et al. The Lancet. 2021;397(10288):1905-1913.
While research shows that better nurse staffing ratios are associated with improved patient outcomes, policies setting minimum nurse-to-patient ratios in hospitals are rarely implemented. In 2016, select Queensland (Australia) hospitals implemented minimum nurse staffing ratios. Compared to hospitals that did not implement minimum nurse staffing ratios, length of stay, mortality, and readmission rates were significantly lower in intervention hospitals, providing evidence, once again, that minimum staffing ratios can improve patient outcomes. 
Thomas J, Dahm MR, Li J, et al. Health Expect. 2021;24(2):222-233.
Missed or failure to follow up on test results threatens patient safety. This qualitative study used volunteers to explore consumer perspectives related to test result management. Participants identified several challenges that patients experience with test-results management, including systems-level factors related to the emergency department and patient-level factors impacting understanding of test results.
Rosen IEW, Shiekh RM, Mchome B, et al. Acta Obstet Gynecol Scand. 2021;100(4):704-714.
Improving maternal safety is an ongoing patient safety priority. This systematic review concluded that maternal near miss events are negatively associated with various aspects of quality of life. Women exposed to maternal near miss events were more likely to have overall lower quality of life, poorer mental and social health, and suffer negative economic consequences.
Sexton JB, Adair KC, Profit J, et al. Jt Comm J Qual Patient Saf. 2021;47(7):403-411.
Health system leadership practices can influence patient safety. Using a cross-sectional survey of clinical and non-clinical healthcare workers, this study found that Positive Leadership WalkRounds – where leadership conduct rounds and ask staff about what is going well and what can be improved – was associated with improved safety culture and healthcare worker well-being. Healthcare workers exposed to Postive Leadership WalkRounds were more likely to report readiness to engage in quality improvement activities, positive perceptions of teamwork and work-life balance norms and were less likely to report emotional exhaustion in themselves and their colleagues. 

Cifra CL, Westlund E, Ten Eyck P, et al. Diagnosis (Berl). 2021;8(2):193-198. doi: 10.1515/dx-2020-0023.

Missed sepsis diagnosis can lead to increased morbidity, mortality and length of stay. Using administrative data, this retrospective study estimated the risk of potentially missed pediatric sepsis in several emergency departments. Approximately 8% of pediatric patients admitted to the hospital with sepsis experienced a treat-and-release emergency department visit within the prior 7 days. Administrative data can be helpful for hospitals in identifying cases that require detailed record review as well as evaluating the impact of sepsis alerts and bundles.
Kurteva S, Abrahamowicz M, Gomes T, et al. JAMA Netw Open. 2021;4(5):e218782.
Using administrative data and patient interviews, this study sought to estimate opioid-related adverse events in adults discharged from one Canadian hospital. Among patients who filled at least one opioid prescription in the 90 days following hospital discharge, approximately 16% experienced an opioid-related emergency department visit, hospital readmission, or death. Longer duration of use and higher daily dose were associated with increased risk of adverse events. Results from this study can inform policies and strategies to limit opioid prescription dose and duration.  
Thomas J, Dahm MR, Li J, et al. Health Expect. 2021;24(2):222-233.
Missed or failure to follow up on test results threatens patient safety. This qualitative study used volunteers to explore consumer perspectives related to test result management. Participants identified several challenges that patients experience with test-results management, including systems-level factors related to the emergency department and patient-level factors impacting understanding of test results.
McHugh MD, Aiken LH, Sloane DM, et al. The Lancet. 2021;397(10288):1905-1913.
While research shows that better nurse staffing ratios are associated with improved patient outcomes, policies setting minimum nurse-to-patient ratios in hospitals are rarely implemented. In 2016, select Queensland (Australia) hospitals implemented minimum nurse staffing ratios. Compared to hospitals that did not implement minimum nurse staffing ratios, length of stay, mortality, and readmission rates were significantly lower in intervention hospitals, providing evidence, once again, that minimum staffing ratios can improve patient outcomes. 
Sullivan KM, Le PL, Ditoro MJ, et al. J Patient Saf. 2021;17(4):311-315.
High-alert medications have the potential to cause serious patient harm. A brief survey of pharmacy staff, nurses, and physicians found that less than half expressed confidence in their knowledge of high-alert medications.  After implementation of an intervention to enhance staff knowledge of high-alert medications, confidence significantly increased, and most respondents could correctly identify high alert medications and associated procedures.
Antognini JF. J Patient Saf. 2021;17(4):e274-e279.
Using ten years of Centers for Medicare and Medicaid Services (CMS) hospital deficiency data, this study determined conditions of participation (CoP) in each deficiency. Patient death was more likely to be associated with the determination of immediate jeopardy (the most serious potential risk). The most common reason for the determination of immediate jeopardy was failure to provide adequate nursing care. These results can help guide hospitals in improving healthcare delivery and patient safety.
Sinha P, Pischel L, Sofair AN. Diagnosis (Berl). 2021;8(2):157-160.
Reducing diagnostic error is essential to patient safety. This article describes the use of structured education sessions and deliberate practice with senior clinicians to improve diagnostic skills among medical residents. These sessions focused on generating differential diagnoses and identifying cognitive errors and knowledge gaps.
Polancich S, Hall AG, Miltner RS, et al. J Healthc Qual. 2021;43(3):137-144.
The COVID-19 pandemic has disrupted many aspects of health care delivery, including how hospitals prevent common hospital-acquired conditions such as pressure injuries. Based on retrospective data, the authors of this study did not identify a longitudinal increase in hospital-acquired pressure injuries between March and July 2020. The authors discuss how prior organizational efforts to reduce hospital-acquired pressure injuries allowed their hospital to quickly adapt existing workflows and processes to respond to the COVID-19 pandemic.
Rosen IEW, Shiekh RM, Mchome B, et al. Acta Obstet Gynecol Scand. 2021;100(4):704-714.
Improving maternal safety is an ongoing patient safety priority. This systematic review concluded that maternal near miss events are negatively associated with various aspects of quality of life. Women exposed to maternal near miss events were more likely to have overall lower quality of life, poorer mental and social health, and suffer negative economic consequences.
Sexton JB, Adair KC, Profit J, et al. Jt Comm J Qual Patient Saf. 2021;47(7):403-411.
Health system leadership practices can influence patient safety. Using a cross-sectional survey of clinical and non-clinical healthcare workers, this study found that Positive Leadership WalkRounds – where leadership conduct rounds and ask staff about what is going well and what can be improved – was associated with improved safety culture and healthcare worker well-being. Healthcare workers exposed to Postive Leadership WalkRounds were more likely to report readiness to engage in quality improvement activities, positive perceptions of teamwork and work-life balance norms and were less likely to report emotional exhaustion in themselves and their colleagues. 
Della Torre V, E. Nacul F, Rosseel P, et al. Anaesthesiol Intensive Ther. 2021;Epub May 20.
Human factors (HF) is the interaction between workers, equipment, and the environment. The COVID-19 pandemic has accelerated the adoption of HF in intensive care units across the globe. This paper expands on the core concepts of HF and proposes the additional key concepts of agility, serendipity, innovation, and learning. Adoption of these HF concepts by leadership and staff can improve patient safety in intensive care units in future pandemics and other crisis situations.
Petrone G, Brown L, Binder W, et al. Disaster Med Public Health Prep. 2021;Epub Mar 26.
As COVID-19 infections surged worldwide, many states set up alternative care hospitals (ACH), or field hospitals. Prior to opening a Rhode Island ACH, four multi-disciplinary in situ simulation scenarios were run to perform system testing. This in situ simulation was successful in identifying patient safety concerns, resulting in equipment modification and protocol changes.
Azyabi A. Int J Environ Res Public Health. 2021;18(5):2466.
Accurate measurement of patient safety culture (PSC) is essential to improving patient safety. This review summarizes the results of 66 studies on PSC in hospitals. Multiple instruments were used to assess PSC, including the Hospital Survey on Patient Safety Culture (HSPSC) and the Safety Attitudes Questionnaire (SAQ). Teamwork and organization and behavioral learning were identified as critical factors impacting PSC and should be considered in future research.
Jones A, Blake J, Adams M, et al. Health Policy. 2021;125(3):375-384.
A key component of patient safety culture is the ability of staff to speak up about patient safety concerns without fear of repercussions. An analysis of 34 studies on speaking-up behavior revealed two narrative themes on why interventions were or were not successful: hierarchical, interdisciplinary, and cultural relationships, and psychological safety. Although interventions varied, there were international similarities in workplace norms and culture. Improving speaking-up behavior in healthcare settings is complex and no intervention is one-size-fits-all.
Price T, Wong G, Withers L, et al. Med Educ. 2021;Epub Mar 28.
Remediation programs are used to address unprofessional behavior contributing to adverse events. This literature review found that remediation programs are effective when a doctor’s insight and motivation are developed and behavior change is reinforced. This can be accomplished through activities such as safe spaces, goal setting, and destigmatizing remediation.

National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021.

Maternal safety is challenged by clinical, equity, and social influences. This virtual event examined maternal health conditions in the United States to improve health system practice and performance for this population. Discussions addressed the need for better data collection, evidence-based practice, and social determinants knowledge integration to enhance the safety of care.

Jones J, Treiber L, Shabo R, et al. Kennesaw, GA: WellStar School of Nursing, WellStar College of Health and Human Services, Kennesaw State University; 2021.

Medication administration practice is a foundational element of nursing education, yet the emphasis on safety is lacking. This report discusses gaps in some nursing programs that detract from building safe medication skills in nurses. Curriculum weaknesses discussed include punitive orientation to nursing student medication errors, lack of error prevention instruction, and insufficient opportunities for competency development to support peers that make mistakes.

Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Devices and Radiological Health. May 20, 2021.

Magnetic resonance imaging (MRI) suites harbor unique hazards that can harm patients, should process missteps occur. This report shares assessment steps to assure that medical devices are labeled appropriately to support their safe use in the MRI environment and encourages organizational reporting of problems encountered when testing device use.

This Month’s WebM&Ms

WebM&M Cases
Spotlight Case
Kriti Gwal, MD |
A 52-year-old man complaining of intermittent left shoulder pain for several years was diagnosed with a rotator cuff injury and underwent left shoulder surgery. The patient received a routine follow-up X-ray four months later. The radiologist interpreted the film as normal but noted a soft tissue density in the chest and advised a follow-up chest X-ray for further evaluation. Although the radiologist’s report was sent to the orthopedic surgeon’s office, the surgeon independently read and interpreted the same images and did not note the soft tissue density or order any follow-up studies. Several months later, the patient’s primary care provider ordered further evaluation and lung cancer was diagnosed. The commentary discusses how miscommunication contributes to delays in diagnosis and treatment and strategies to facilitate effective communication between radiologists and referring clinicians.  
WebM&M Cases
David T. Martin, MD and Diane O’Leary, PhD |
Beginning in her teenage years, a woman began "feeling woozy" after high school gym class. The symptoms were abrupt in onset, lasted between 5 to 15 minutes and then subsided after sitting down. Similar episodes occurred occasionally over the following decade, usually related to stress. When she was in her 30s, she experienced a more severe episode of palpitations and went to the emergency department (ED). An electrocardiogram (ECG) was normal and she was discharged with a diagnosis of stress or possible panic attack. She continued to experience these symptoms for two more years and her primary care physician (PCP) suggested that she see a psychiatrist for presumed panic attacks. At the patient’s request, the PCP ordered a 24-hour Holter monitor, which was normal. When she was 40 years old, the patient experienced another severe episode and went to the ED. During an exercise treadmill test, she experienced another “woozy” spell and the ECG showed an elevated heart rate with narrow QRS complexes. She was diagnosed with paraoxymal supraventricular tacycardia (PSVT). The commentary discusses the diagnostic challenges of PSVT and approaches to reduce diagnostic uncertainty, especially given gender bias in attributing palpitations to psychiatric rather than cardiac causes.
WebM&M Cases
Christian Bohringer, MBBS |
A 34-year-old morbidly obese man was placed under general anesthesia to treat a pilonidal abscess. Upon initial evaluation by an anesthesiologist, he was found to have a short thick neck, suggesting that endotracheal intubation might be difficult. A fellow anesthetist suggested use of video-laryngoscopy equipment, but the attending anesthesiologist rejected the suggestion. A first-year resident attempted to intubate the patient but failed. The attending anesthesiologist took over, but before intubation could be performed, the patient desaturated to 40-50%. A second attempt by the attending anesthesiologist at intubation with a glide scope also failed. The patient’s arterial saturation increased after administration of 100% oxygen by mask and he suffered no apparent neurological consequences. The commentary discusses best practices for managing high risk patients and appropriate use of advanced airway management devices.

This Month’s Perspectives

Anjali Joseph
Perspectives on Safety
Anjali Joseph, PhD, EDAC, is a Spartanburg Regional Healthcare System Endowed Chair in Architecture and Health Design. Molly M. Scanlon, PhD, FAIA, FACHA, is the Director at Phigenics, LLC. We spoke with them about how healthcare built environments have been temporarily modified during the COVID-19 pandemic and what learnings may be used moving forward.
Perspective
This piece discusses areas where the healthcare built environment may contribute to the risk of COVID-19 transmission, mitigating strategies, and how the pandemic may impact the built environment moving forward.
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