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June 23, 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

Koeck JA, Young NJ, Kontny U, et al. Paediatr Drugs. Epub 2021 May 8. 

Pediatric patients are at risk for medication prescribing errors due to weight-based dosing. This review analyzed 70 interventions aimed at reducing weight-based prescribing errors. Findings indicate that bundled interventions are most effective, and that interventions should include substitute or engineering controls (e.g., computerized provider order entry) along with administrative controls (e.g., expert consultation).
Busch IM, Moretti F, Campagna I, et al. Int J Environ Res Public Health. 2021;18(10):5080.
Clinicians involved in unexpected patient outcomes can experience negative emotions and frequently need access to second victim support programs. This systematic review describing 12 second victim support programs identifies staff benefits, implementation challenges, and experiences of peer supporters. Affected staff and peer supporters reported the benefits of the programs. Challenges included blame culture, limited awareness of program existence, and lack of financial resources. Findings indicate a need for implementing new second victim support programs, promoting current programs, and monitoring peer supporters’ well-being.

Patel J, Otto E, Taylor JS, et al. Dermatol Online J. 2021;27(3).

In an update to their 2010 article, this review’s authors summarized the patient safety literature in dermatology from 2009 to 2020. In addition to topics covered in the 2010 article, this article also includes diagnostic errors related to telemedicine, laser safety, scope of practice, and infections such as COVID-19. The authors recommend further studies, and reports are needed to reduce errors and improve patient safety.
Stokke R, Melby L, Isaksen J, et al. BMC Health Serv Res. 2021;21(1):553.
This article explored the interface of technology and patients in home care. Researchers identified three work processes that contribute to patient safety: aligning people with technologies, being alert and staying calm, and coordinating activities based on people and technology. Topics for future research should include the division of labor on home care shifts, the need for new routines and education in telecare for care workers, and how decisions are made regarding home technology.
Abraham J, Meng A, Sona C, et al. Int J Med Inform. 2021;151:104458.
Standardized handoff protocols from the operating room to the intensive care unit have improved patient safety, but clinician compliance and long-term sustainability remain poor. This study identified four phases of post-operative handoff associated with risk factors: pre-transfer preparation, transfer and set up, report preparation and delivery, and post-transfer care. The authors recommend “flexibly standardized” handoff intervention tools for safe transfer from operating room to intensive care.
Aftab H, Shah SHH, Habli I. Stud Health Technol Inform. 2021;281:659-663.
Patients are increasingly using the internet and conversational agents (CAs) like Siri, Alexa, and Google to find answers to their healthcare questions. Investigators used these CAs to detect errors and failures in calculating correct insulin doses. Failure classes include misunderstanding and misrecognition of words. Potential failures must be considered before deployment of CAs in safety-critical environments.
Holmqvist M, Thor J, Ros A, et al. BMC Health Serv Res. 2021;21(1):557.
Polypharmacy in older adults puts them at risk for adverse drug events. In interviews with primary care clinicians, researchers found that working conditions and working in partnership with colleagues, patients, and family influenced medication evaluation. They also identified two main areas of action: working with a plan and collaborative problem-solving. 
Weprin SA, Meyer D, Li R, et al. Patient Saf Surg. 2021;15(1):14.
A retained surgical sharp (RSS) is a never event. Operating room (OR) team members, including surgeons, anesthesiologists, and nurses, were surveyed regarding their experiences with actual and near-miss sharps (NMS). While nearly all team members reported experiencing at least one RSS or NMS in the past year, responses to other survey items varied by professional group. Surgeons were less likely to perceive that a sharp had been lost as compared to other OR team members, indicating a potential under-report bias. Improved communication between team members may increase identification, and therefore reporting, of RSS and NMS, to prevent similar incidents in the future.
Shafiee Hanjani L, Hubbard RE, Freeman CR, et al. Intern Med J. 2021;51(4):520-532.
Cognitively impaired older adults living in residential aged care facilities (RACF) are at risk of adverse drug events related to potentially inappropriate polypharmacy. Based on telehealth visits with 720 RACF residents, 66% were receiving polypharmacy, with cognitively intact residents receiving significantly more medications than cognitively impaired residents. Overall, 82% of residents were receiving anti-cholinergic medications which should be avoided in this population. Future interventions and research should pay particular attention to the prescribing of these medications.
Kabir R, Liaw S, Cerise J, et al. J Pharm Pract. 2021:089719002110212.
The best possible medication history (BPMH) is the gold standard of medication reconciliation of a patient’s prescribed and over-the-counter medications. In this study, Certified Pharmacy Technicians (CPhTs) obtained BPMH from patients admitted through the emergency department. In Quality Assurance reviews, the CPhTs identified medication discrepancies at a similar rate to pharmacists, indicating that CPhTs may be a cost-effective alternative to pharmacists in obtaining BPMH.
Norris B, Soncrant C, Mills PD, et al. Jt Comm J Qual Patient Saf. 2021;47(8):489-495.
Opioid misuse and overdose continues to be a patient safety concern. This study conducted root cause analyses of 82 adverse event reports involving opioid use at the Veterans Health Administration. The most frequent event type was medication administration error and the most frequent root cause was staff not following hospital policies or hospitals not having opioid-related policies. 
Pifarré i Arolas H, Vidal-Alaball J, Gil J, et al. Int J Environ Res Public Health. 2021;18(10):5335.
The beginning of the COVID-19 pandemic immediately changed how patients sought healthcare. This study analyzed the change frequency of diagnoses made in 2019 compared to 2020 in one region of Spain. On average, the number of diagnoses declined 31% from 2019 to 2020, with cancer diagnoses declining by nearly 50%. As COVID-19 cases continue to decrease in many areas in 2021, the authors recommend local, regional, and national public health leaders prioritize plans to target under-diagnosed conditions.
Walters GK. J Patient Saf. 2021;17(4):e264-e267.
The majority of preventable adverse events are multifactorial in nature and are a result of system failures. Using a case study, the authors outline a series of errors following misplacement of a PICC line. Failures include differences in recording electronic health record notes and communication between providers. Investigations of all adverse events will help identify and correct system failures to improve patient safety.
Placona AM, Rathert C. Med Care Res Rev. 2021:107755872110145.
This systematic review analyzed results of 32 studies comparing online patient reviews (OPRs) and measures of patient outcomes. While OPRs did have positive associations with patient experience, associations between OPRs and quality measures were mixed. Due to the weight that patients give OPRs, future research should focus on associations between OPRs and encounter setting, specialty, and specific quality measures.

Koeck JA, Young NJ, Kontny U, et al. Paediatr Drugs. Epub 2021 May 8. 

Pediatric patients are at risk for medication prescribing errors due to weight-based dosing. This review analyzed 70 interventions aimed at reducing weight-based prescribing errors. Findings indicate that bundled interventions are most effective, and that interventions should include substitute or engineering controls (e.g., computerized provider order entry) along with administrative controls (e.g., expert consultation).

Patel J, Otto E, Taylor JS, et al. Dermatol Online J. 2021;27(3).

In an update to their 2010 article, this review’s authors summarized the patient safety literature in dermatology from 2009 to 2020. In addition to topics covered in the 2010 article, this article also includes diagnostic errors related to telemedicine, laser safety, scope of practice, and infections such as COVID-19. The authors recommend further studies, and reports are needed to reduce errors and improve patient safety.
Busch IM, Moretti F, Campagna I, et al. Int J Environ Res Public Health. 2021;18(10):5080.
Clinicians involved in unexpected patient outcomes can experience negative emotions and frequently need access to second victim support programs. This systematic review describing 12 second victim support programs identifies staff benefits, implementation challenges, and experiences of peer supporters. Affected staff and peer supporters reported the benefits of the programs. Challenges included blame culture, limited awareness of program existence, and lack of financial resources. Findings indicate a need for implementing new second victim support programs, promoting current programs, and monitoring peer supporters’ well-being.
Shao Q, Wang Y, Hou K, et al. J Adv Nurs. 2021;Epub Jun 5.
Patient suicide in all settings is considered a never event. Nurses caring for the patient may experience negative psychological symptoms following inpatient suicide. This review identified five themes based on nurses’ psychological experiences: emotional experience, cognitive experience, coping strategies, self-reflection, and impact on self and practice. Hospital administrators should develop education and support programs to help nurses cope in the aftermath of inpatient suicide.  
No results.
Multi-use Website

The Society for Post-Acute and Long-Term Care Medicine.

Polypharmacy is a known challenge to patient safety. This collective program encourages long-term care organizations, physicians, and pharmacists to take part in a learning network to share aggregated data, lessons learned, and educational opportunities to reduce medication adverse events through safe deprescribing. 

Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.

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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