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September 1, 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

Churruca K, Ellis LA, Pomare C, et al. BMJ Open. 2021;11(7):e043982.
Safety culture has been studied in healthcare settings using a variety of methods. This systematic review identified 694 studies of safety culture in hospitals. Most used quantitative surveys, and only 31 used qualitative or mixed methods. Eleven themes were identified, with leadership being the most common; none of the methods or tools appeared to measure all 11 themes. The authors recommend that future research include both qualitative and quantitative methods.
Fernandez Branson C, Williams M, Chan TM, et al. BMJ Qual Saf. 2021;Epub Jul 27.
Receiving feedback from colleagues may improve clinicians’ diagnostic reasoning skills. By building on existing models such as Safer Dx, and collaborating with professionals outside of the healthcare field, researchers developed the Diagnosis Learning Cycle, a model intended to improve diagnosis through peer feedback.
Watterson TL, Stone JA, Brown RL, et al. J Am Med Inform Assoc. 2021;28(7):1526-1533.
Prior research has found that ambulatory electronic health records cannot communicate medication discontinuation instructions to pharmacies. In this study, the implementation of the CancelRx system led to a significant, sustained increase in successful medication discontinuations and reduced the time between medication discontinuation in the clinic EHR and pharmacy dispensing software.
Watterson TL, Stone JA, Brown RL, et al. J Am Med Inform Assoc. 2021;28(7):1526-1533.
Prior research has found that ambulatory electronic health records cannot communicate medication discontinuation instructions to pharmacies. In this study, the implementation of the CancelRx system led to a significant, sustained increase in successful medication discontinuations and reduced the time between medication discontinuation in the clinic EHR and pharmacy dispensing software.
Taylor M, Reynolds C, Jones RM. Patient Safety. 2021;3(2):45-62.
Isolation for infection prevention and control – albeit necessary – may result in unintended consequences and adverse events. Drawing from data submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS), researchers explored safety events that impacted COVID-19-positive or rule-out status patients in insolation. The most common safety events included pressure injuries or other skin integrity events, falls, and medication-related events.
Speaks L, Helmer SD, Quinn KR, et al. J Surg Educ. 2021;Epub Aug 4.
Balancing resident autonomy and supervision is an ongoing challenge in medical training. The authors reviewed patient data to identify adverse outcomes (e.g., complications, readmissions, reoperation, mortality) undergoing common general surgery procedures performed by, or indirectly supervised by, attending surgeons or the chief resident service. Findings suggest that indirect supervision of appendectomies, cholecystectomies, and hernia repairs by the chief resident surgery service is safe and can serve as a model to enhance resident autonomy during training.
Douglas RN, Stephens LS, Posner KL, et al. Br J Anaesth. 2021;127(3):470-478.
Effective communication among providers helps ensure patient safety. Through analysis of perioperative malpractice claims using the Anesthesia Closed Claims Project database, researchers found that communication failures contributed to 43% of total claims, with the majority between the anesthesiologist/anesthesia team and the surgeon/surgery team. Methods to improve perioperative communication are discussed.
Neprash HT, Sheridan B, Jena AB, et al. Health Aff (Millwood). 2021;40(8):1321-1327.
The COVID-19 pandemic led to an increase in the use of telehealth in order to limit patient exposure to the virus. Findings from this study highlight the value of telehealth visits for patients with suspected respiratory infections to prevent further transmission. Researchers found that patients exposed to influenza-like illness in primary care office settings were more likely than nonexposed patients to return with a similar illness within two weeks.
Mikos M, Banas T, Czerw A, et al. Int J Environ Res Public Health. 2021;18(15):8167.
Patient falls resulting in injury are considered a never event. In this analysis of falls within one hospital, rates and trends varied across six clinical departments. The highest rate of falls was seen in rehabilitation and internal medicine, and the lowest rate in orthopedic and rheumatology. Clinical department, rates, and trends should be considered when implementing fall prevention strategies.
Van Eerd D, D'Elia T, Ferron EM, et al. J Safety Res. 2021;78:9-18.
Working conditions for healthcare workers can affect patient safety. Conducted at four long-term care facilities in Canada, this study found that a participatory organizational change program can have positive impacts on identifying and reducing musculoskeletal disorder hazards for employees, including slips, trips, falls, and ergonomic hazards. Key factors for successful implementation of the change program include frontline staff involvement/engagement, support from management, and training.
Anderson E, Mohr DC, Regenbogen I, et al. J Patient Saf. 2021;17(4):316-322.
Burnout and low staff morale have been associated with poor patient safety outcomes. This study focused on the association between organizational climate, burnout and morale, and the use of seclusion and restraints in inpatient psychiatric hospitals. The authors recommend that initiatives aimed at reducing restraints and seclusion in inpatient psychiatric facilities also include a component aimed at improving organizational climate and staff morale.
Chua K-P, Brummett CM, Conti RM, et al. Pediatrics. 2021;Epub Aug 16.
Despite public policies and guidelines to reduce opioid prescribing, providers continue to overprescribe these medications to children, adolescents, and young adults. In this analysis of US retail pharmacy data, 3.5% of US children and young adults were dispensed at least one opioid prescription; nearly half of those included at least one factor indicating they were high risk. Consistent with prior research, dentists and surgeons were the most frequent prescribers, writing 61% of all opiate prescriptions.
King CR, Abraham J, Fritz BA, et al. PLoS ONE. 2021;16(7):e0254358.
Analysis of canceled medication orders has been used to estimate medication ordering errors. Using the same dataset analyzed in their 2017 study, the authors update the analysis using machine learning to predict medication ordering errors and associated factors. Results indicate machine learning may be useful in understanding risk factors involved with medication ordering errors.
Pinheiro LC, Reshetnyak E, Safford MM, et al. Med Care. 2021;Epub Aug 14.
Prior research has found that racial/ethnic minorities may be at higher risk for adverse patient safety outcomes. This study evaluated racial disparities in self-reported adverse events based on cross-sectional survey data collected as part of a national, prospective cohort evaluating stroke mortality. Findings show that Black participants were significantly more likely to report a preventable adverse event attributable to poor care coordination (e.g., drug-drug interaction, emergency department visitor, or hospitalization) compared to White participants.
Petrosoniak A, Fan M, Hicks CM, et al. BMJ Qual Saf. 2021;30(9):739-746.
Trauma resuscitation is a complex, specialized process with a high risk for errors. Researchers analyzed videotapes of in situ simulations to evaluate latent safety events occurring during trauma resuscitation. Themes influencing latent safety events related to physical workspace, mental model formation, equipment, unclear accountability, demands exceeding individuals’ capacity, and task-specific issues.
Fernandez Branson C, Williams M, Chan TM, et al. BMJ Qual Saf. 2021;Epub Jul 27.
Receiving feedback from colleagues may improve clinicians’ diagnostic reasoning skills. By building on existing models such as Safer Dx, and collaborating with professionals outside of the healthcare field, researchers developed the Diagnosis Learning Cycle, a model intended to improve diagnosis through peer feedback.

Li L, Childs AW. J Psychiatr Pract. 2021;27(4):245-253.

Although telehealth has been available for some time, its use increased exponentially at the onset of the COVID-19 pandemic. Using the Six Domains of Health Care Quality (safe, timely, effective, efficient, equitable, patient-centered), the authors outline a framework to evaluate the safety and quality of psychiatric and behavioral health care provided via telehealth for older adults and disadvantaged youths.
Churruca K, Ellis LA, Pomare C, et al. BMJ Open. 2021;11(7):e043982.
Safety culture has been studied in healthcare settings using a variety of methods. This systematic review identified 694 studies of safety culture in hospitals. Most used quantitative surveys, and only 31 used qualitative or mixed methods. Eleven themes were identified, with leadership being the most common; none of the methods or tools appeared to measure all 11 themes. The authors recommend that future research include both qualitative and quantitative methods.

Clinical Human Factors Group. October 19, 2021. 9:00AM - 12:00 PM (eastern).

The application of human factors and ergonomics methods to healthcare process design results in proactive failure reduction opportunities. This virtual conference will discuss the Systems Engineering Initiative for Patient Safety (SEIPS) framework to describe how this sociotechnical model supports system safety. Speakers include Pascale Carayon, Andrew Petrosoniak and Richard Holden.
Upcoming Meeting/Conference

Washington Patient Safety Coalition. October 6-7, 2021.

This annual virtual conference will highlight regional and local experiences driving improvement in health equity, diagnostic safety, and patient engagement. Sidney Dekker and John D. Banja are among the speakers.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.

Delays in treatment due to device misuse or design flaws can result in patient harm. This recall announcement highlights the omission of instructions describing a distinct device feature that, if a surgeon is unaware of it, reduces emergent umbilical vein catheter placement safety. Two deaths have been reported due to problems with the device.

Center for Healthy Aging--New York Academy of Medicine, Yale School of Nursing.

Healthcare-associated infections (HAIs) challenge safety in long-term care. This toolkit highlights multidisciplinary approaches to reducing HAIs and teaching tools focused on distinct audiences across the continuum to share principles and tactics supporting improvement.

Outcalt C. The Atlantic. August 2021.

Overuse and unnecessary care lead to serious patient harms and a cascade of negative consequences. This story describes the overuse behavior of one surgeon to illustrate influences contributing to the problem.

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.
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