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June 9, 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

Hada A, Coyer F. Nurs Health Sci. 2021;23(2):337-351.
Safe patient handover from one nursing shift to the next requires complete and accurate communication between nurses. This review aimed to identify which nursing handover interventions result in improved patient outcomes (i.e., patient falls, pressure injuries, medication administration errors). Interventions differed across the included studies, but results indicate that moving the handover to the bedside and using a structured approach, such as Situation, Background, Assessment, Recommendation (SBAR) improved patient outcomes.
Krancevich NM, Belfer JJ, Draper HM, et al. Ann Pharmacother. 2021;Epub May 18.
Prescribing opioids to opioid-naïve patients after hospital discharge may lead to chronic use. This study evaluated long-term opioid use among patients admitted directly to the ICU and who received intravenous opioids. While long-term opioid use was more common among patients who received an opioid prescription at discharge, the authors did not find a significant relationship between ICU opioid prescribing in opioid-naïve patients and long-term opioid use. The authors suggest future research focus on transitions from hospital to home or other post-acute sites to reduce inappropriate opioid use.
Hunt DF, Bailey J, Lennox BR, et al. Int J Ment Health Syst. 2021;15(1):33.
Psychological safety has been widely studied in a variety of settings, clinical areas, and patient outcomes. This commentary lays out the benefits of safety culture and how it can be implemented organization-wide, with a particular focus on mental health organizations. Specific interventions are discussed, including family involvement, leadership communication, and simulation.
Wright MI, Polivka B, Abusalem S. AORN J. 2021;113(5):465-475.
Prior research identified variability in perioperative safety culture by provider type and experience. This study found that perioperative nurse engagement (e.g., energy, dedication, resilience) and perioperative nurse certification were significantly associated with self-reported safety culture in the operating room, but length of perioperative nurse experience was not.
Kakemam E, Chegini Z, Rouhi A, et al. J Nurs Manag. 2021;Epub May 10.
Clinician burnout, characterized by emotional exhaustion, depersonalization, and decreased sense of accomplishment, can result in worse patient safety outcomes. This study explores the association of nurse burnout and self-reported occurrence of adverse events during COVID-19. Results indicate higher levels of nurse burnout were correlated with increased perception of adverse events, such as patient and family verbal abuse, medication errors, and patient and family complaints. Recommendations for decreasing burnout include access to psychosocial support and human factors approaches.
Synan LT, Eid MA, Lamb CR, et al. Surgery. 2021;Epub May 25.
This study compared unsolicited hospital reviews posted online by patients with Hospital Compare patient satisfaction and postsurgical safety indicators. While there was variation in consumer ratings between platforms, unstructured consumer reviews were generally correlated with Hospital Compare patient satisfaction scores; consumer platforms were not consistently correlated with postsurgical patient safety indicators.
Singh D, Fahim G, Ghin HL, et al. J Pharm Pract. 2021;34(3):354-359.
Pharmacist-led medication reconciliation has been found to reduce medication discrepancies for some patients. This retrospective study examined the impact of pharmacist-conducted medication reconciliation among patients with chronic obstructive pulmonary disease (COPD). While pharmacist-conducted medication reconciliation identified medication dosing and frequency errors, it did not reduce 30-day readmission rates for patients with COPD.
Mitchell OJL, Neefe S, Ginestra JC, et al. Resusc Plus. 2021;6:100135.
Rapid response teams (RRT) are intended to improve the identification and management of clinically worsening hospitalized patients. This study identified an increase in RRT activations for respiratory distress at one academic hospital during the COVID-19 pandemic. The authors outline the hospital response, which included revising RRT guidelines to reduce in-room personnel, new decision-support pathways, which accounted for COVID-19 uncertainty, and expanded critical care consults for inpatient care team.
Krancevich NM, Belfer JJ, Draper HM, et al. Ann Pharmacother. 2021;Epub May 18.
Prescribing opioids to opioid-naïve patients after hospital discharge may lead to chronic use. This study evaluated long-term opioid use among patients admitted directly to the ICU and who received intravenous opioids. While long-term opioid use was more common among patients who received an opioid prescription at discharge, the authors did not find a significant relationship between ICU opioid prescribing in opioid-naïve patients and long-term opioid use. The authors suggest future research focus on transitions from hospital to home or other post-acute sites to reduce inappropriate opioid use.
Gambashidze N, Hammer A, Wagner A, et al. J Patient Saf. 2021;17(4):e280-e287.
Correctly reporting, interpreting, and comparing patient safety culture (PSC) survey findings is critical to improving patient safety in hospitals. Nearly 1,800 physicians and nurses were surveyed using the Hospital Survey on Patient Safety Culture (HSOPS) to examine the influence of gender, profession, and managerial function on perception of patient safety culture. Results indicate that profession and managerial function had significant direct effects, while gender had indirect effects, on the Overall Perception of Patient Safety dimension. Hospitals should take these characteristics into account when interpreting PSC survey results.  
Vanhaecht K, Zeeman G, Schouten L, et al. J Nurs Manag. 2021;Epub Apr 25.
Peer support programs can help clinicians cope with the emotional consequences of involvement in an adverse event. This cross-sectional survey of Dutch nurses and doctors found that most respondents (86%) had been involved in a patient safety incident at some point during their career but only a small proportion sought out support in the aftermath of the incident.
Leeftink AG, Visser J, de Laat JM, et al. Ergonomics. 2021:1-11.
Failure mode and effect analysis (FMEA) is widely used to identify latent safety hazards. The authors of this study proposed combining healthcare failure mode and effect analysis (HFMEA) with computer simulation (HFMEA-CS) for prospective risk analysis of complex and potentially harmful processes. Use of HFMEA-CS to analyze medication processes during admission and discharge for patients with a rare adrenal tumor led to a reduction in drug delivery and system errors, as well as increased drug adherence.
Reynolds KA, Hellquist K, Ibrahim SA, et al. Arch Dermatol Res. 2021;Epub May 27.
Adverse events associated with pharmacy compounding (e.g., parenteral nutrition, sterile compounding) are well-documented. This survey of state medical and osteopathic boards gathered information about compounding-associated adverse events in physician offices and use of compounding standards. Findings indicate that the incidence of in-office compounding-related adverse events is low and that the majority of respondents had not incorporated compounding standards into their regulations.
Hunt DF, Bailey J, Lennox BR, et al. Int J Ment Health Syst. 2021;15(1):33.
Psychological safety has been widely studied in a variety of settings, clinical areas, and patient outcomes. This commentary lays out the benefits of safety culture and how it can be implemented organization-wide, with a particular focus on mental health organizations. Specific interventions are discussed, including family involvement, leadership communication, and simulation.
Brown SD. Pediatr Radiol. 2021;51(6):1070-1075.
Misdiagnosis of child abuse has far-reaching implications. This commentary discusses the ethical tensions faced by pediatric radiologists of both over- and under-diagnosing child abuse. The author suggests ways that physicians and professional societies can partner with legal advocates to create a more balanced pool of experts to alleviate perceptions of bias and acknowledge harms of misdiagnosed child abuse.
Holden RJ, Carayon P. BMJ Qual Saf. 2021;Epub May 28.
Since the SEIPS (Systems Engineering Initiative for Patient Safety) conceptual model was introduced in 2006, several additional versions have been introduced. In this commentary, the authors of SEIPS 2.0 and SEIPS 3.0 present a practice-oriented SEIPS model (SEIPS 101) along with seven simple tools for use by practitioners, researchers, and others.
Aldila F, Walpola RL. Res Social Adm Pharm. 2021;Epub Apr 4.
Older adults are at increased risk of medicine self-administration errors (MSEs) due to polypharmacy, cognitive decline, and decline in physical abilities. In this review, incorrect dosing was the most common MSE; the most common factor influencing the errors is complex medication regimens due to the need for multiple medications. Additional research is needed into how community pharmacists can assist older adults at risk of MSE.
Hada A, Coyer F. Nurs Health Sci. 2021;23(2):337-351.
Safe patient handover from one nursing shift to the next requires complete and accurate communication between nurses. This review aimed to identify which nursing handover interventions result in improved patient outcomes (i.e., patient falls, pressure injuries, medication administration errors). Interventions differed across the included studies, but results indicate that moving the handover to the bedside and using a structured approach, such as Situation, Background, Assessment, Recommendation (SBAR) improved patient outcomes.
Meeting/Conference Proceedings

Northwest Safety and Quality Partnership. June 22, 2021. 

Diagnostic radiology mistakes contribute to delays and ineffective treatments that contribute to patient harm. This webinar examined factors that contribute to errors in image interpretation and will highlight strategies to learn from those errors to improve diagnostic process reliability. Registering for the program provides access to the recording.

Kritz F. Shots. National Public Radio; May 24, 2021.

Health literacy efforts address challenges related to both language and effective communication tactics. This story discussed how lack of language and information clarity reduced patient education effectiveness during the pandemic and highlights several efforts to address them including information product translation services.

Leape LL. Cham, Switzerland: Springer Nature; 2021. ISBN: 978-3030711252.

The publication of “Error in Medicine” by Dr. Lucian Leape marked a pivotal step in the launch of the modern patient safety movement. In this publication, Dr. Leape shares insights stemming from his notable career in safety to outline milestones in the current effort to reduce patient harm due to medical mistakes.

Farnborough, UK: Healthcare Safety Investigation Branch; April 22, 2021.

Wrong-site surgery in dentistry is a frequent and persistent never event. This report examines a case of pediatric wrong tooth extraction to reveal how the application of safety standards is influenced by the work environment and discusses the use of forcing functions to create barriers to error in practice.

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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