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August 4, 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

Chong LSH, Kerklaan J, Clarke S, et al. JAMA Pediatr. 2021;Epub Jul 19.
Transgender and nonbinary individuals may delay or avoid seeking necessary healthcare due to fears of discrimination. This systematic review of qualitative studies of the perspectives of transgender youths identified six major themes regarding their experiences with accessing healthcare, including fear, vulnerability, and systemic barriers. The authors recommend several strategies to improve access to healthcare for transgender individuals.
Mulac A, Mathiesen L, Taxis K, et al. BMJ Qual Saf. 2021;Epub Jul 22.
Barcode medication administration (BCMA) is a mechanism to prevent adverse medication events, but unintended consequences have also been reported when BCMA is not used appropriately. Researchers observed nurses administering medications and identified task-related, organizational, technological, environmental, and nurse-related BCMA policy deviations. Researchers provide several strategies for hospitals wishing to implement or improve BCMA systems.
van der Kooi T, Lepape A, Astagneau P, et al. Euro Surveill. 2021;26(23).
Healthcare-associated infections (HAIs) contribute to patient morbidity and mortality every year. Three mortality review measures were developed to measure the potential contribution of HAIs to patient death. All three measures showed acceptable feasibility, validity, and reproducibility in HAI surveillance.
Small K, Sidebotham M, Gamble J, et al. Midwifery. 2021;102:103074.
Health information technologies intended to reduce patient harm may have unintended consequences (UC). Midwives describe the unintended consequences of central fetal monitoring technology. These consequences included potential loss of patient trust in the midwife, changes in clinical practice, and increased documentation during labor. The authors recommend reevaluation of use of central fetal monitoring due to potential UC without demonstrating improvements in maternal safety.
Mulac A, Mathiesen L, Taxis K, et al. BMJ Qual Saf. 2021;Epub Jul 22.
Barcode medication administration (BCMA) is a mechanism to prevent adverse medication events, but unintended consequences have also been reported when BCMA is not used appropriately. Researchers observed nurses administering medications and identified task-related, organizational, technological, environmental, and nurse-related BCMA policy deviations. Researchers provide several strategies for hospitals wishing to implement or improve BCMA systems.
Foster C, Doud L, Palangyo T, et al. Pediatr Qual Saf. 2021;6(4):e434.
Healthcare worker safety has been linked to overall safety culture. A pediatric hospital adapted patient safety event reporting infrastructure and definitions to worker safety reporting. Implementation of the worker safety reporting system reduced time from injury to reporting, identified safety gaps, and improved worker satisfaction with the reporting process.
Serre N, Espin S, Indar A, et al. J Nurs Care Qual. 2021;Epub Jul 15.
Safety concerns are common in long-term care (LTC) facilities. This qualitative study of LTC nurses explored nurses’ experiences managing patient safety incidents (PSI). Three categories were identified: commitment to resident safety, workplace culture, and emotional reaction. Barriers and facilitators were also discussed.
Alshehri GH, Keers RN, Carson-Stevens A, et al. J Patient Saf. 2021;17(5):341-351.
Medication errors are common in mental health hospitals. This study found medication administration and prescribing were the most common stages of medication error. Staff-, organizational-, patient-, and equipment-related factors were identified as contributing to medication safety incidents.
van der Kooi T, Lepape A, Astagneau P, et al. Euro Surveill. 2021;26(23).
Healthcare-associated infections (HAIs) contribute to patient morbidity and mortality every year. Three mortality review measures were developed to measure the potential contribution of HAIs to patient death. All three measures showed acceptable feasibility, validity, and reproducibility in HAI surveillance.
Galanter W, Eguale T, Gellad WF, et al. JAMA Netw Open. 2021;4(7):e2117038.
One element of conservative prescribing is minimizing the number of medications prescribed. This study compared the number of unique, newly prescribed medications (personal formularies) of primary care physicians across four health systems. Results indicated wide variability in the number of unique medications at the physician and institution levels. Further exploration of personal formularies and core drugs may illuminate opportunities for safer and more appropriate prescribing.
Jaam M, Naseralallah LM, Hussain TA, et al. PLOS ONE. 2021;16(6):e0253588.
Including pharmacists can improve patient safety across the medication prescribing continuum. This review identified twelve pharmacist-led educational interventions aimed at improving medication safety. The phase, educational strategy, patient population, and audience varied across studies; however most showed some reductions in medication errors.
Claydon O, Keeler B, Khanna A. Int J Qual Health Care. 2021;33(3).
Patient complaints may provide insight into patient safety. Three hundred and ninety-nine patient or family complaints against the surgery departments at one United Kingdom hospital were examined. A quarter of those complaints related to communication with hospital staff, 24% were related to out-of-hospital delays, and 22% were clinical issues. Interventions aimed at improving communication with patients and families may improve patient experiences.
Ellahham S. Am J Med Qual. 2021;Epub Jul 22.
Linguistic, culture, and health literacy barriers between patients and providers can lead to adverse events. In addition to the use of professional interpreters, the authors suggest additional culturally and linguistically appropriate services (CLAS) to improve communication between patients, particularly refugees and migrants, and providers.
Morris AH, Stagg B, Lanspa M, et al. J Am Med Inform Assoc. 2021;28(6):1330-1344.
Clinical decision support systems are designed to improve clinical decision-making. The authors of this commentary suggest an alternative, eActions, to reduce clinician burden and increase replicability. Dissemination and use of eActions could contribute to improved clinical care quality and research.
Kappes M, Romero‐García M, Delgado‐Hito P. Int Nurs Rev. 2021;Epub Jun 13.
Healthcare professionals who experience negative physical, psychological, or behavioral responses following an adverse event may be referred to as “second victims.” This review describes personal and organizational support strategies as well as barriers faced by second victims who are seeking support. The authors recommend further evaluation of support programs and implementation of support programs in Latin America.
Chong LSH, Kerklaan J, Clarke S, et al. JAMA Pediatr. 2021;Epub Jul 19.
Transgender and nonbinary individuals may delay or avoid seeking necessary healthcare due to fears of discrimination. This systematic review of qualitative studies of the perspectives of transgender youths identified six major themes regarding their experiences with accessing healthcare, including fear, vulnerability, and systemic barriers. The authors recommend several strategies to improve access to healthcare for transgender individuals.
No results.

Jt Comm J Qual Patient Saf. 2021;47(8):463-488. 

The Eisenberg Award honors individuals and organizations who have made significant advancements in the pursuit of safe, high-quality health care. 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.

London, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016. 

Lack of appropriate follow up of diagnostic imaging can result in care delays, patient harm, and death. This report summarizes an investigation of 25 imaging failures in the British National Health Service (NHS). The analysis identified communication and coordination issues resulting in lack of action and reporting of unanticipated findings to properly advance care. Recommendations to improve imaging in the NHS include use of previous analyses to enhance learning from failure.

This Month’s WebM&Ms

WebM&M Cases
Minna Wieck, MD |
A seven-year-old girl with esophageal stenosis underwent upper endoscopy with esophageal dilation under general anesthesia. During the procedure, she was fully monitored with a continuous arterial oxygen saturation probe, heart rate monitors, two-lead electrocardiography, continuous capnography, and non-invasive arterial blood pressure measurements. The attending gastroenterologist and endoscopist were serially dilating the esophagus with larger and larger rigid dilators when the patient suddenly developed hypotension. She was immediately given a fluid bolus, phenylephrine, and 100% oxygen but still developed cardiac arrest. Cardiopulmonary resuscitation was initiated with cardiac massage, but she could not be resuscitated and died. This commentary highlights the role of communication between providers, necessary technical steps to mitigate the risks of upper endoscopy in children, and the importance of education and training for care team members.
WebM&M Cases
Narath Carlile, MD, MPH, Soheil El-Chemaly, MD, MPH, and Gordon D. Schiff, MD |
A 31-year-old woman presented to the ED with worsening shortness of breath and was unexpectedly found to have a moderate-sized left pneumothorax, which was treated via a thoracostomy tube. After additional work-up and computed tomography (CT) imaging, she was told that she had some blebs and mild emphysema, but was discharged without any specific follow-up instructions except to see her primary care physician. Three days later, the patient returned to the same ED with similar symptoms and again was found to have had a left pneumothorax that required chest tube placement, but the underlying cause was not established. After she was found two weeks later in severe respiratory distress, she was taken to another ED by paramedics where the consulting pulmonary physician diagnosed her with a rare cystic lung disease. The commentary discusses the importance of CT scans for evaluating spontaneous pneumothorax and educating providers to increase awareness of rare cystic lung diseases.
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.

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.
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