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July 14, 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

Melnyk BM, Tan A, Hsieh AP, et al. Am J Crit Care. 2021;30(3):176-184.
This survey of 771 critical care nurses found that 40% had at least one symptom of depression and nearly half experienced some degree of anxiety. Nurses with poor physical or mental health reported making more medical errors than their healthier counterparts and nurses in supportive workplaces were more likely to have better physical and mental health. The authors suggest that improvements in an organization’s health and wellness support programs could result in fewer reported medical errors. Notably, this study was completed prior to the COVID-19 pandemic which has led to an even further decline in nurse wellness. 
Silvera GA, Wolf JA, Stanowski A, et al. Patient Exp J. 2021;8(1):30-39.
Research has found that families and caregivers play a key role in identifying and preventing patient safety events.  Based on a national sample of hospitals, this study explored the impact of hospital visitation restrictions during the COVID-19 pandemic on patient experience and safety outcomes. Results indicate that hospitals with closed visitations experienced larger performance deficits across measures of medical staff responsiveness, fall rates, and sepsis rates.
Ziemba JB, Berns JS, Huzinec JG, et al. Acad Med. 2021;96(7):997-1001.
Root cause analysis (RCA) is a common method to investigate adverse events and identify contributing factors. To expand resident understanding of and participation in RCA, the authors developed simulated RCAs that were applicable to a broad set of specialties and included other healthcare professionals whose disciplines were involved in the event (e.g., nurses, pharmacists). After participating in the simulated RCAs, there was an increase in trainees understanding of RCA and intent to report adverse events.
Kasick RT, Melvin JE, Perera ST, et al. Diagnosis (Berl). 2021;8(2):209-217.
Diagnostic errors can result in increased length of stay and unplanned hospital readmissions. To reduce readmissions, this hospital implemented a diagnostic time-out to increase the frequency of documented differential diagnosis in pediatric patients admitted with abdominal pain. Results showed marginal improvement in quality of differential diagnosis.
Melnyk BM, Tan A, Hsieh AP, et al. Am J Crit Care. 2021;30(3):176-184.
This survey of 771 critical care nurses found that 40% had at least one symptom of depression and nearly half experienced some degree of anxiety. Nurses with poor physical or mental health reported making more medical errors than their healthier counterparts and nurses in supportive workplaces were more likely to have better physical and mental health. The authors suggest that improvements in an organization’s health and wellness support programs could result in fewer reported medical errors. Notably, this study was completed prior to the COVID-19 pandemic which has led to an even further decline in nurse wellness. 
Strid EN, Wåhlin C, Ros A, et al. BMC Health Serv Res. 2021;21(1).
Based on semi-structured interviews with healthcare workers in Sweden, the authors explored how individuals, team members and managers respond to critical incidents. Critical incidents are emotionally distressing for healthcare workers but teamwork and trust among teams can facilitate safe practices and help individuals overcome emotional distress. Respondents also highlighted the importance of organizational support for managing risks, individual closure, and providing support after an incident.
Stolldorf DP, Ridner SH, Vogus TJ, et al. Implement Sci Commun. 2021;2(1):63.
Implementing effective interventions supporting medication reconciliation is an ongoing challenge. Using qualitative data, the authors explored how different hospitals implemented one evidence-based medication reconciliation toolkit. Thematic analyses suggest that the most commonly used implementation strategies included restructuring (e.g., altered staffing, equipment, data systems); quality management tools (e.g., audit and feedback, advisory boards); thorough planning and preparing for implementation; and education and training with stakeholders.
Fauer AJ. Herd. 2021;Epub Jun 26.
The physical design or layout of a clinical space can affect patient safety.  This mixed-methods study of 8 ambulatory oncology offices found that the physical layout (e.g., visibility of patients during infusion) and location (i.e., proximity of infusion center to prescribers) impacted communication and patient safety. Consultation with clinicians regarding the physical environment prior to design of ambulatory oncology clinics could improve communication and therefore patient safety.
Silvera GA, Wolf JA, Stanowski A, et al. Patient Exp J. 2021;8(1):30-39.
Research has found that families and caregivers play a key role in identifying and preventing patient safety events.  Based on a national sample of hospitals, this study explored the impact of hospital visitation restrictions during the COVID-19 pandemic on patient experience and safety outcomes. Results indicate that hospitals with closed visitations experienced larger performance deficits across measures of medical staff responsiveness, fall rates, and sepsis rates.
Casciato DJ, Thompson J, Law R, et al. J Foot Ankle Surg. 2021;Epub Jun 4.
The "July Effect" refers to the idea there may be an increase in medical errors in July when newly graduated medical students begin their residencies. In this retrospective chart review of podiatric surgery patients, researchers did not find any statistically significant difference in patient outcomes between surgeries performed during the first quarter of residency (July-September) and the last quarter (April-June). Results suggest robust resident training programs can limit errors that may otherwise occur during this time of transition.  
Ziemba JB, Berns JS, Huzinec JG, et al. Acad Med. 2021;96(7):997-1001.
Root cause analysis (RCA) is a common method to investigate adverse events and identify contributing factors. To expand resident understanding of and participation in RCA, the authors developed simulated RCAs that were applicable to a broad set of specialties and included other healthcare professionals whose disciplines were involved in the event (e.g., nurses, pharmacists). After participating in the simulated RCAs, there was an increase in trainees understanding of RCA and intent to report adverse events.
Khan NF, Booth HP, Myles P, et al. BMC Health Serv Res. 2021;21.
This study assessed how and when quality improvement (QI) feedback reports on prescribing safety are used in one general practice in the UK. Four themes were identified: receiving the report, facilitators and barriers to acting upon the report, acting upon the report, and how the report contributes to a quality culture. Facilitators included effective dissemination of reports while barriers included lack of time to act upon the reports. As most practitioners indicated the QI reports were useful, efforts should be made to address barriers to acting upon the reports.
Nævestad T-O, Storesund Hesjevoll I, Elvik R. Accid Anal Prev. 2021;159:106228.
Healthcare organizations are increasingly investing in promoting culture of safety to improve patient safety outcomes but few, if any, regulations exist influencing safety culture in healthcare. In a review of how regulators influence safety culture in several high-reliability fields, the authors identified six relationships between regulators and safety behavior and accidents. If healthcare regulators are to successfully influence safety culture in healthcare, attention must be paid to each relationship.
Strand NH, Mariano ER, Goree JH, et al. Mayo Clin Proc. 2021;96(6):1394-1400.
Systemic racism in healthcare can threaten patient safety and contribute to heath disparities. This commentary outlines an “inside-out” approach to fostering antiracism in pain medicine and suggests approaches to stem systemic racism in training programs, practice settings, device and pharmaceutical industry, and professional organizations.
Sujan M, Habli I. BMJ Qual Saf. 2021;Epub May 27.
This commentary discusses the use of “safety cases” to communicate the safety of a product, system or service in industry (e.g., aviation, defense, railways). Using an example of a smart infusion pump, the authors discuss how to apply this concept in healthcare to support the safe adoption of digital health innovations.
Spencer RA, Singh Punia H. Patient Educ Couns. 2021;104(7):1681-1703.
Communication failures during transitions of care can threaten safe patient care. Although this systematic review identified several tools to support communication between inpatient providers and patients during transitions from hospital to home, the authors did not identify any existing tools to support the post-discharge period in primary care.
Awan M, Zagales I, McKenney M, et al. J Surg Educ. 2021;Epub Jun 30.
In 2011, the Accreditation Council for Graduate Medical Education (ACGME) updated the duty hour restrictions (DHR) for medical residents to increase resident well-being. This review focused on surgical patient outcomes, resident case volume, and resident quality of life following the implementation of the 2011 update. Results showed DHR did not improve patient safety or surgical resident quality of life. The authors suggest future revisions meant to improve resident well-being not focus solely on hours worked in a single shift or week.
Mangal S, Pho A, Arcia A, et al. Jt Comm J Qual Patient Saf. 2021;47(9):591-603.
Interventions to prevent catheter-associated urinary tract infections (CAUTI) can include multiple components such as checklists and provider communication. This systematic review focused on CAUTI prevention interventions that included patient and family engagement. All included studies showed some improvement in CAUTI rates and/or patient- and family-related outcomes. Future research is needed to develop more generalizable interventions.
No results.

Schapiro R. NBC News. June 27, 2021.

System failures cause care delays in a wide range of patient segments. This news story describes barriers to safe, patient-centered care experienced by overweight patients such as bias, ineffective space consideration, and lack of access to screening equipment.

Washington, DC: Department of Veterans Affairs, Office of Inspector General. June 24, 2021. Report No. 19-09808-171.

This report examined veterans' health clinic use of telemental health to identify safety challenges inherent in this approach before the expansion of telemedine during the COVID-19 crisis. The authors note the complexities in managing emergent mental health situations in virtual consultations. Recommendations for improvement included emergency preparedness planning, specific reporting of telemental health incidents and organized access to experts.

Health Ethics & Governance, World Health Organization. Geneva, Switzerland: World Health Organization; 2021.  ISBN: 9789240029200

Advanced computing technologies can help or hinder safe care. This guidance summaries ethical concerns and risks stemming from the influx of artificial intelligence (AI) into decision making throughout health care. The report provides 6 tenets to guide AI implementation worldwide and shares governance recommendations to ensure the clinical and public health impacts of AI are equitable, responsible and safe.

ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2.

High-alert medication misadministration is of great concern due to the increased opportunity for harm associated with mistakes. This case describes how tubing and alarm management errors came together to result in the death of patient sedated with fentanyl.

Rockville, MD: Agency for Healthcare Research and Quality; June 2021.

The use of antibiotics should be monitored to reduce the potential for infection in care facilities. This toolkit outlines offers a methodology for launching or invigorating an antibiotic stewardship program. Designed to align with four time elements of antibiotic therapy, its supports processes that enable safety for nursing home residents.

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.  

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.
Perspectives on Safety
This piece discusses EMS patient safety concerns in the field and discusses operational concerns, clinical concerns, and safety of personnel.
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