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June 16, 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

Debesay J, Kartzow AH, Fougner M. Nurs Inq. 2021;Epub May 13.
Previous studies have shown that ethnic minority patients are at an increased risk of adverse events. Using critical incidents and provider reflections, this study highlights the challenges faced by healthcare providers when providing care for ethnic minority patients. Similar reflection processes in the work environment may contribute to better coping strategies and improved relationships with ethnic minority patients. 
Holstine JB, Samora JB. Jt Comm J Qual Patient Saf. 2021;47(9):563-571.
Errors in surgical specimen handling can cause treatment delays or missed diagnoses. This children’s hospital implemented a quality improvement effort to reduce surgical specimen errors. Using a variety of methods, including changes to specimen labeling, improved communication, and specimen time-out, they were able to decrease the mean rate of order errors and labeling-related errors.
Murphy A, Griffiths P, Duffield C, et al. J Adv Nurs. 2021;77(8):3379-3388.
Some adverse events are sensitive to aspects of nursing care, including pressure injuries, falls, hospital-acquired urinary tract infections, and medication administration errors. This retrospective study, based on patient discharge data from three Irish hospitals, characterized nursing-sensitive adverse events and associated costs. Results indicate that 16% of patients experienced at least one nurse-sensitive adverse event during their inpatient stay and that each additional nurse-sensitive adverse event was associated with a significant increase in length of stay. Extrapolated nationally, the authors estimate the economic burden of nurse-sensitive adverse events to the Irish health system to be €91.3 million annually.
DeGrave AJ, Janizek JD, Lee S-I. Nature Machine Intel. 2021;Epub May 31.
Artificial intelligence (AI) systems can support diagnostic decision-making. This study evaluates diagnostic “shortcuts” learned by AI systems in detecting COVID-19 in chest radiographs. Results reveal a need for better training data, improved choice in the prediction task, and external validation of the AI system prior to dissemination and implementations in different hospitals.  
Geva A, Albert BD, Hamilton S, et al. Pediatr Crit Care Med. 2021;Epub May 4.
Checklists are used in many clinical settings to improve patient safety. This pediatric intensive care unit updated a static checklist, eSIMPLE, to a dynamic, decision-support enhanced checklist, eSIMPLER. The eSIMPLER checklist took less time to complete, had higher user satisfaction, and improved adherence to best-practices.
Murphy A, Griffiths P, Duffield C, et al. J Adv Nurs. 2021;77(8):3379-3388.
Some adverse events are sensitive to aspects of nursing care, including pressure injuries, falls, hospital-acquired urinary tract infections, and medication administration errors. This retrospective study, based on patient discharge data from three Irish hospitals, characterized nursing-sensitive adverse events and associated costs. Results indicate that 16% of patients experienced at least one nurse-sensitive adverse event during their inpatient stay and that each additional nurse-sensitive adverse event was associated with a significant increase in length of stay. Extrapolated nationally, the authors estimate the economic burden of nurse-sensitive adverse events to the Irish health system to be €91.3 million annually.
Smits M, Langelaan M, de Groot J, et al. J Patient Saf. 2021;17(4):282-289.
This study used trained reviewers to examine root causes of adverse events in 571 deceased hospital patients in the Netherlands. Preventable adverse events were commonly caused by technical, organizational, and human causes; technical causes also commonly contributed to preventable deaths from adverse events. The authors discuss strategies to reduce adverse events, including improving communication and information structures, evaluating safety behaviors, and continuous monitoring of patient safety and quality data.
Carman E-M, Fray M, Waterson P. Appl Ergon. 2021;93:103339.
This study analyzed incident reports, discharge planning meetings, and focus groups with hospital and community healthcare staff to identify barriers and facilitators to safe transitions from hospital to community. Barriers included discharge tasks not being complete, missing or inaccurate information, and limited staff capacity. Facilitators include  improved staff capacity and good communication between hospital staff, community healthcare staff, and family members. The authors recommend that hospital and community healthcare staff perspectives be taken into account when designing safe discharge policies.
Debesay J, Kartzow AH, Fougner M. Nurs Inq. 2021;Epub May 13.
Previous studies have shown that ethnic minority patients are at an increased risk of adverse events. Using critical incidents and provider reflections, this study highlights the challenges faced by healthcare providers when providing care for ethnic minority patients. Similar reflection processes in the work environment may contribute to better coping strategies and improved relationships with ethnic minority patients. 
Tobiano G, Chaboyer W, Dornan G, et al. Aging Clin Exp Res. 2021;Epub May 5.
Medication safety, particularly among older adults who may have complex medication regimens, is an ongoing safety concern. This study explored medication safety behaviors among young-old (65-74 years), middle-old (75-84 years) and old-old (>85 years) adults. The authors found that older adults are willing to engage in medication safety behaviors, but that preferred behaviors (e.g., verbal behaviors, self-administering medication, reviewing medication charts) differed among the age groups.
Holstine JB, Samora JB. Jt Comm J Qual Patient Saf. 2021;47(9):563-571.
Errors in surgical specimen handling can cause treatment delays or missed diagnoses. This children’s hospital implemented a quality improvement effort to reduce surgical specimen errors. Using a variety of methods, including changes to specimen labeling, improved communication, and specimen time-out, they were able to decrease the mean rate of order errors and labeling-related errors.
Sharma V, Kulkarni V, Eurich DT, et al. BMJ Open. 2021;11(5):e043964.
Opioids are high-risk medications and a significant source of patient harm. Using administrative data for over 390,000 adult patients in Alberta, Canada, who received an opioid prescription from 2017-2018, the authors developed machine learning models to estimate the 30-day risk of opioid-related adverse outcomes. Findings suggest that incorporating hospitalization or physician claims into the models can improve predictive performance, as compared to the inclusion of guidelines or prescribing history alone.
Wu F, Dixon-Woods M, Aveling E-L, et al. Soc Sci Med. 2021;280:114050.
Reluctance of healthcare team members to speak up about concerns can hinder patient safety. The authors conducted semi-structured interviews with 156 participants (health system leadership, managers, healthcare providers, and staff) about policies, practice, and culture around voicing concerns related to quality and safety. Findings suggest that both formal and informal hierarchies can undermine the ability and desire of individuals to speak up, but that informal organization (such as personal relationships) can motivate and support speaking up behaviors.

Wands B. AANA J. 2021;89(2):168-174.

Healthcare professionals who experience emotional consequences after adverse events are often referred to as “second victims.” Targeted towards certified registered nurse anesthetists (CRNAs), this article discusses second victim experiences in anesthesiology and implications for anesthesia education and training.
Killin L, Hezam A, Anderson KK, et al. Jt Comm J Qual Patient Saf. 2021;47(7):438-451.
Medication errors at hospital discharge are a common cause of medication errors and adverse drug events (ADE). This review compared three types of discharge medication reconciliation: paper-based, electronic, and enhanced. Results suggest electronic medication reconciliation reduced the odds of a medication discrepancy or ADE, as compared to paper-based. Results were mixed on enhanced medication reconciliation.
Mangory KY, Ali LY, Rø KI, et al. BMC Health Serv Res. 2021;21(1):369.
Burnout may adversely affect patient safety and clinician wellness. This review of studies using the Maslach Burnout Inventory (MBI) found that only four of 11 studies found an association between clinician burnout and observed adverse patient care. The authors recommend further research into the association of burnout and patient safety using the MBI.
Pati D, Valipoor S, Lorusso L, et al. J Patient Saf. 2021;17(4):273-281.
Decreasing inpatient falls requires improvements in both processes of care and the care environment. This integrative review found that some elements of the built environments have not been rigorously examined and concluded that objective and actionable knowledge on physical design solutions to reduce falls is limited.  
No results.

Oakbrook Terrace, IL: Joint Commission: June 8, 2021.

The Eisenberg Award honors individuals and organizations who have made critical achievements toward patient safety and quality improvement. The 2020 honorees are Dr. David Gaba, Veterans Health Administration Rapid Naloxone Initiative, Washington, DC, and Northwestern Medicine Academy for Quality and Safety Improvement, Chicago IL. The awards will be presented virtually during the National Quality Forum's annual meeting in July.

The Agency for Healthcare Research and Quality. Fed Register. 2021;86(103): 29263-29264.

Measurement of diagnostic errors is an important challenge in health care. This announcement calls for the review of Common Formats for Event Reporting--Diagnostic Safety or CFER-DS, and supplies links to the draft formats for public comment. The development of a standard system for voluntary reporting of diagnostic errors to patient safety organizations will support effective data collection and measurement. The process for submitting comments is now closed.

Ross C. Stat News. June 2, 2021.

Artificial intelligence and machine learning are often promoted as tools with impressive potential for generating rapid improvements in healthcare decision making. This news story highlights how underlying problems and testing failures limit the trustworthiness of conclusions drawn by the systems.

Office of Inspector General. June 2, 2021. Report No. 18-02496-157.

Health systems can exacerbate potential risk for patient harm due to clinician impairment and unprofessional activities. This report examines a long-term situation that, due to failure of reporting and other system issues, enabled over 3,000 diagnostic delay injuries stemming from specimen errors associated with one pathologist.

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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