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July 7, 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

Dickinson KL, Roberts JD, Banacos N, et al. Health Secur. 2021;19(S1):S14-S26.
The COVID-19 pandemic highlighted the continued existence of structural racism and its disproportionate impact on the health of communities of color. This study examines the experiences of non-White and White communities and the negative impact of structural racism on the non-White communities. The authors call for bold action emphasizing the need for structural changes.  
Abela G. J Tissue Viability. 2021;Epub Jun 3.
Hospital-acquired pressure injuries (HAPI) can lead to increase costs and length of stay. Through root cause analysis, this geriatric rehabilitation hospital identified factors that contributed to the development of HAPI in its facility. Recommendations for improvement targeted both system- and human-level factors.
Sivarajah R, Dinh ML, Chetlen A. J Breast Imaging. 2021;3(2):221-230.
This article describes the Yorkshire contributory factors framework, which identifies factors contributing to safety errors across four hierarchical levels (active errors, situational factors, local working conditions, and latent factors) and two cross-cutting factors (communication systems and safety culture). The authors apply this framework to a case of missed mass on breast imaging and discuss how its use can help health systems effectively learn from error and develop systematic, proactive programs to improve safety and manage safety issues.
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PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. Sign up today to get weekly and monthly updates via emails!

This Month’s WebM&Ms

WebM&M Cases
Cynthia Li, PharmD, and Katrina Marquez, PharmD |
This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.
WebM&M Cases
Robin Aldwinckle, MD |
A 61-year-old male was admitted for a right total knee replacement under regional anesthesia. The surgeon – unaware that the anesthesiologist had already performed a right femoral nerve block with 20 ml (100mg) of 0.5% racemic bupivacaine for postoperative analgesia – also infiltrated the arthroplasty wound with 200 mg of ropivacaine. The patient was sedated with an infusion of propofol throughout the procedure. At the end of the procedure, after stopping the propofol infusion, the patient remained unresponsive, and the anesthesiologist diagnosed the patient with Local Anesthetic Systemic Toxicity (LAST). The commentary addresses the symptoms of LAST, the importance of adhering to local anesthetic dosing guidelines, and the essential role of effective communication between operating room team members.
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.  
Card AJ. Disaster Med Public Health Prep. 2021:1-3.
While health professional burnout and stress related to the COVID-19 pandemic have been documented in previous studies, this study focuses on risk managers and patient safety professionals. More than 70% of participants qualified as burned out. Common sources of stress included social distancing, changing duties, and impacts of the virus. Knowing the sources of stress can guide programs to decrease burnout in this population.
Dynan L, Smith RB. Health Serv Outcomes Res Methodol. 2021.
Peer review is one strategy for assessing clinical performance and uncovering potential safety issues. Based on hospital discharge and expenditure data from 2004 – 2015 in Florida, the authors found a significant beneficial effect of increased hospital expenditure on peer review and patient safety outcomes.
Adams KT, Pruitt Z, Kazi S, et al. J Patient Saf. 2021;Epub May 20.
It is important to consider unintended consequences when implementing new tools, such as health information technology (HIT). This study reviewed 2,700 patient safety event reports to identify the type of medication error, the stage in the process in which the error occurred, and how HIT usability issues contributed to the errors. Errors in dosing were the most frequent type, and occurred during ordering or reviewing. Most errors described usability issues which should be considered and addressed to improve medication safety.
Langevin M, Ward N, Fitzgibbons C, et al. Simul Healthc. 2021;Epub Jun 18.
Prior research has found that simulation-based event analysis (SBEA) can identify novel sources of error as well as generate creative strategies for error prevention. In this study, researchers found that simulation can optimize SBEA-generated recommendations and that it provides opportunity to test the intervention in real-life settings before widespread implementation.
Abela G. J Tissue Viability. 2021;Epub Jun 3.
Hospital-acquired pressure injuries (HAPI) can lead to increase costs and length of stay. Through root cause analysis, this geriatric rehabilitation hospital identified factors that contributed to the development of HAPI in its facility. Recommendations for improvement targeted both system- and human-level factors.
Jakonen A, Mänty M, Nordquist H. Jt Comm J Qual Patient Saf. 2021;Epub Jun 1.
Checklists have been implemented in a variety of specialties and settings to improve safe patient care. In this study, researchers developed and pilot-tested safety checklists for emergency response driving (ERD) and patient transport in Finland. Semi-structured interviews with paramedics and ERD drivers indicated that the safety checklists improved perceived safety.
Chung EH, Truong T, Jooste KR, et al. J Surg Educ. 2021;78(3):942-949.
Medical residents are frequently involved in difficult patient conversations, including error disclosure. This paper describes the development and implementation of a novel communications/didactic skills training program for OB/GYN residents. Immediately, and 3-months after training, residents indicated an improvement in their communication skills.
Blease CR, Salmi L, Hägglund M, et al. JMIR Ment Health. 2021;8(6):e29314.
This commentary outlines six benefits of the new requirement that health systems offer online patient access to their medical records, including clinician notes. Benefits include strengthened patient-clinician relationships, patient engagement, and adherence to mental health care plans. While online access may help narrow the digital divide, the authors also point out that lack of access to technology is still a barrier.
Sivarajah R, Dinh ML, Chetlen A. J Breast Imaging. 2021;3(2):221-230.
This article describes the Yorkshire contributory factors framework, which identifies factors contributing to safety errors across four hierarchical levels (active errors, situational factors, local working conditions, and latent factors) and two cross-cutting factors (communication systems and safety culture). The authors apply this framework to a case of missed mass on breast imaging and discuss how its use can help health systems effectively learn from error and develop systematic, proactive programs to improve safety and manage safety issues.
Wu AW, Vincent CA, Shapiro DW, et al. J Patient Saf Risk Manag. 2021;26(3):93-96.
The July effect is a phenomenon that presumably results in poor care due to the annual en masse introduction of new doctors into practice. This commentary outlines factors undermining the safe influx of these new clinicians into active, independent practice. The authors discuss how a systemic approach is required to situate these practitioners to provide the safest care possible.
Fischer CP, Bilimoria KY, Ghaferi AA. JAMA. 2021;326(2):179-180.
Rapid response teams (RRTs) are intended to quickly identify clinical deterioration and prevent intensive care unit transfer, cardiac arrest, or death. This article summarizes the evidence included in the AHRQ Making Healthcare Safer III report about the use of RRTs to decrease failure to rescue. Although utilization is widespread, the authors conclude that definitive evidence that RRTs are associated with reduced rates of failure to rescue is inconclusive. The authors note that evidence does support that RRTs are associated with reduced secondary outcomes, such as ICU transfer rate and cardiac arrest.
Dickinson KL, Roberts JD, Banacos N, et al. Health Secur. 2021;19(S1):S14-S26.
The COVID-19 pandemic highlighted the continued existence of structural racism and its disproportionate impact on the health of communities of color. This study examines the experiences of non-White and White communities and the negative impact of structural racism on the non-White communities. The authors call for bold action emphasizing the need for structural changes.  

Ross NE, Newman WJ. J Am Acad Psychiatry Law. Epub 2021 May 21.

Open disclosure of errors and adverse events is increasingly encouraged in healthcare, but clinicians frequently cite fear of malpractice lawsuits as a reason to avoid apologizing for an error. This commentary summarizes the relationship between apologies and malpractice, the emergency of apology laws in the United States, and research exploring the impact of apology laws on malpractice claims and patient outcomes.
Clari M, Conti A, Chiarini D, et al. J Nurs Care Qual. 2021;Epub Apr 15.
Handovers between providers occur regularly during hospital stays. This review synthesizes the benefits of, and barriers to, successful handovers. Benefits include humanization of the patient and improved patient safety; barriers include provider stress and feelings of inadequacy. Recognition of these factors can improve successful implementation of handover procedures in hospitals.
Osborne V. Curr Opin Psychiatry. 2021;34(4):357-362.
The opioid epidemic is an ongoing patient safety issue. This literature review examined the impact of the COVID-19 pandemic on opioid surveillance research in the United Kingdom. Of studies conducted during the pandemic, most explored the impact of the pandemic on access to opioids or opioid substitution therapy.
Manias E, Bucknall T, Hutchinson AM, et al. Expert Opin Drug Saf. 2021:1-19.
Medication errors are a common cause of preventable harm in long-term care facilities. This systematic review explored how residents and families engage in medication management in aged care facilities. Factors hindering effective engagement included insufficient communication between residents, families, and providers; families’ hesitation about decision making; and lack of provider training.

Armstrong Institute for Patient Safety and Quality. October 11, 15 and 20, 2021.

Human factors engineering (HFE) is a primary strategy for advancing safety in health care. This virtual workshop will introduce HFE methods and discuss how they can be used to reduce risk through design improvements in a variety of process and interpersonal situations.

Saks M, Landsman S. New York, NY: Oxford University Press; 2021.  ISBN: 9780190667986.

A weave of systemic factors contributes to the persistent presence of error in medicine. This publication summarizes the development of the patient safety movement and discusses legal and policy approaches as promising avenues for generating the changes needed to reduce iatrogenic harm and sustain improvement.

Rosen M, Ali KJ, Buckley BO, et al. Rockville, MD; Agency for Healthcare Research and Quality: June 2021.

The mindset on diagnostic error improvement has gone from a focus on individual skills to that of system factors. This issue brief highlights the influence health system executives have on amending the care environment to facilitate the most effective environment for diagnostic accuracy. This is the latest in a publication series examining diagnostic improvement across health care.

Department of Defense Office of General Counsel. 32 CFR Part 45. Fed Register. 86(115); June 17, 2021:32194-32215.

Organizations with safety cultures facilitate the ability for an injured patient to seek an effective response to untoward incidents. This United States rule outlines the standards that enable members of the armed forces to file claims should they be harmed while in the military health care system.

This Month’s Perspectives

James_Augustine
Interview
James Augustine, MD, is the National Director of Prehospital Strategy at US Acute Care Solutions where he provides service as a Fire EMS Medical Director. We spoke with him about threats and concerns for patient safety for EMS when responding to a 911 call.
Perspective
This piece discusses EMS patient safety concerns in the field and discusses operational concerns, clinical concerns, and safety of personnel.