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July 21, 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
Arvidsson L, Lindberg M, Skytt B, et al. J Clin Nurs. 2021;31:878-894.
Healthcare associated infections (HAI) affect thousands of hospitalized patients each year. This study evaluated working conditions that impact risk behaviors, such as missed hand hygiene, that may contribute to HAI. Main findings indicate that interruptions and working with colleagues were associated with increased risk behaviors.
Baughman AW, Triantafylidis LK, O'Neil N, et al. Jt Comm J Qual Patient Saf. 2021;47:646-653.
Medication reconciliation is the process of reviewing a patient’s medication list for discrepancies and safety. Patients in nursing homes are at increased risk for medication discrepancies due to complexity of care and frequent transitions of care. By using Healthcare Failure Mode and Effect Analysis (FMEA), researchers uncovered several factors that contribute to medication discrepancies. Interventions to improve medication safety can be targeted to one or more of the contributing factors.
Fournier JP, Amélineau JB, Hild S, et al. Eur J Gen Pract. 2021;27(1):142-151.
The COVID-19 pandemic has raised new patient safety concerns. This study examined patient safety incidents in primary care settings in France during the early months of the COVID-19 pandemic. Of the 132 reported incidents, 44% related to delayed diagnosis, assessments and referrals. Reported incidents less commonly related to cancellation of care, home confinement-related incidents, and inappropriate medication discontinuation.
Mackenhauer J, Winsløv J-H, Holmskov J, et al. Crisis. 2021;43:307-314.
Prior research has found that patients who die by suicide often had recent contact with the healthcare setting. Based on a multi-year chart review at one institution, the authors concluded that suicide risk assessment and documentation in the heath record to be insufficient. The authors outline quality improvement recommendations focused on improving documentation, suicide assessment and intervention training, and improving communications with families, caregivers, and other health care providers.
Udeh C, Canfield C, Briskin I, et al. J Am Med Inform Assoc. 2021;28:1791-1795.
Computerized provider order entry (CPOE) systems have the potential to reduce error, but their poor CPOE design, implementation and use can contribute to patient safety risks. In this study, researchers found that restricting the number of concurrently open electronic health records did not significantly reduce wrong patient selection errors in their hospital’s CPOE system.
Werner NE, Rutkowski RA, Krause S, et al. Appl Ergon. 2021;96:103509.
Shared mental models contribute to effective team collaboration and communication. Based on interviews and thematic analysis, the authors explored mental models between the emergency department (ED) and skilled nursing facility (SNF). The authors found that these healthcare professionals had misaligned mental models regarding communication during care transitions and healthcare setting capability, and that these misalignments led to consequences for patients, professionals, and the organization.
Allison MK, Marshall SA, Stewart G, et al. J Emerg Med. 2021;61:396-405.
Transgender and gender nonbinary (trans/NB) people can face discriminatory behaviors when accessing health care services. Trans/NB patients were interviewed about their experiences accessing care in emergency departments. Four themes were uncovered: 1) system and structural issues; 2) interactions with clinicians/staff; 3) perceptions of clinician knowledge and education; and 4) impact on future health and healthcare access. Recommendations for improvement were provided at the system and clinician level.
Arvidsson L, Lindberg M, Skytt B, et al. J Clin Nurs. 2021;31:878-894.
Healthcare associated infections (HAI) affect thousands of hospitalized patients each year. This study evaluated working conditions that impact risk behaviors, such as missed hand hygiene, that may contribute to HAI. Main findings indicate that interruptions and working with colleagues were associated with increased risk behaviors.
Baughman AW, Triantafylidis LK, O'Neil N, et al. Jt Comm J Qual Patient Saf. 2021;47:646-653.
Medication reconciliation is the process of reviewing a patient’s medication list for discrepancies and safety. Patients in nursing homes are at increased risk for medication discrepancies due to complexity of care and frequent transitions of care. By using Healthcare Failure Mode and Effect Analysis (FMEA), researchers uncovered several factors that contribute to medication discrepancies. Interventions to improve medication safety can be targeted to one or more of the contributing factors.
Allen LV, Jr. Int J Pharm Compd. 2021;25:131-139; 222-229.
Intravenous admixture compounding is a complex activity that harbors risks for patients and health care staff. This two-part series reviews the types of errors that compromise the safety of compounding practices, steps in the process where they occur and prevention tactics.
von Vogelsang A‐C, Göransson KE, Falk A‐C, et al. J Nurs Manag. 2021;29:2343-2352.
Incomplete nursing care can be detrimental to care quality and patient safety. This cross-sectional survey of nurses in Sweden at one acute care hospital did not identify significant differences in missed nursing care before and during the COVID-19 pandemic. The authors posit that these results may be attributed to maintaining nurse-patient ratios, sufficient nursing skill mix, and patient mix.
Brummell Z, Vindrola-Padros C, Braun D, et al. BMJ Open. 2021;11:e046619.
Organizations are expected to learn from failures. The National Health Service Secondary Care Trusts (NSCT) are required to report, learn from, and prevent potentially preventable deaths using the ‘Learning from Deaths’ program. Common action themes include reviewing organizational processes and highlighting appropriate guidelines or protocols. Future research should focus on which actions were most successful at decreasing potentially preventable deaths and disseminating that knowledge.
Fournier JP, Amélineau JB, Hild S, et al. Eur J Gen Pract. 2021;27(1):142-151.
The COVID-19 pandemic has raised new patient safety concerns. This study examined patient safety incidents in primary care settings in France during the early months of the COVID-19 pandemic. Of the 132 reported incidents, 44% related to delayed diagnosis, assessments and referrals. Reported incidents less commonly related to cancellation of care, home confinement-related incidents, and inappropriate medication discontinuation.
Diabes MA, Ervin JN, Davis BS, et al. Ann Am Thorac Soc. 2021;18:1027-1033.
A key feature of safety culture is the psychological safety of all staff to feel empowered to speak up about errors or mistakes. In this study of intensive care unit clinicians, job strain, leader inclusiveness and perception of teamwork were associated with psychological safety. However, psychological safety was not associated with performance of either spontaneous breathing trials or lung-protective ventilation. Future research should focus on strategies to improve psychological safety in intensive care units.
Kruper A, Domeyer-Klenske A, Treat R, et al. J Surg Educ. 2021;78:1024-1034.
Physicians commonly experience adverse psychological outcomes after being involved in an adverse event. This mixed-methods study of health care providers in the Department of Obstetrics & Gynecology at one large academic hospital found that three-quarters of providers experienced symptoms of traumatic stress after involvement in an adverse event. Respondents reporting anxiety were more likely to be interested in peer-to-peer support programs, whereas those reporting symptoms of guilt preferred debriefing sessions.
Chang T-P, Bery AK, Wang Z, et al. Diagnosis (Berl). 2022;9:96-106.
A missed or delayed diagnosis of stroke increases the risk of permanent disability or death. This retrospective study compared rates of misdiagnosed stroke in patients presenting to general care or specialty care who were initially diagnosed with “benign dizziness”. Patients with dizziness who presented to general care were more likely to be misdiagnosed than those presenting to specialty care. Interventions to improve stroke diagnosis in emergency departments may also be successful in general care clinics.
Wiegmann DA, J. Wood L, N. Cohen T, et al. J Patient Saf. 2022;18:119-123.
This article reviews the theory behind the Swiss Cheese Model and how organizational influences, supervisory factors, preconditions for unsafe acts, and unsafe acts threaten patient safety.
Zaidi AS, Peterson GM, Bereznicki LRE, et al. Ann Pharmacother. 2021;55:530-542.
Prior research has found that polypharmacy among elderly patients with dementia is associated with greater risk of functional decline. This meta-analysis of five studies concluded that exposure to potentially inappropriate medications (PIM) was not associated with either mortality or hospitalization for patients with cognitive impairment.
Abraham J, Pfeifer E, Doering M, et al. Anesth Analg. 2021;132:1563-1575.
Intraoperative handoffs between anesthesiologists are frequently necessary but are not without risk. This systematic review of 14 studies of intraoperative handoffs and handoff tools found that use of handoff tools has a positive impact on patient safety. Additional research is needed around design and implementation of tools, particularly the use of electronic health records to record handoffs.
No results.
Newspaper/Magazine Article
Meyer H. Kaiser Health News. July 9, 2021.
Whistleblower protections are a key component to raising awareness of safety issues in work environments. This news story examines how US federal law has opened the door for the media as a platform for employees to highlight conditions that reduce staff and patient safety in health care environments.
Newspaper/Magazine Article
Taylor K. American Nurse J. 2021;16(7):14-17.
Medication reconciliation reduces the potential for problems in complicated medication regimens. This article shares strategies for reconciling medications for older patients in the home to ensure their medication use is safe and appropriate.
Toolkit
AHA Team Training and Project Firstline. Chicago, IL: American Hospital Association, Center for Disease Control and Prevention; July 2021.
Problems in communication are common contributors to patient care mistakes. This toolkit draws from experience with the TeamSTEPPS model to highlight best practices in the use of huddles, debriefs and other teamwork improvement strategies.
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
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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