Skip to main content

September 15, 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

Burrus S, Hall M, Tooley E, et al. Pediatrics. 2021;148(3):e2020030346.
Based on analysis of four years of data submitted to the Child Health Patient Safety Organization (CHILDPSO), researchers sought to identify types of serious safety events and contributing factors. Three main groups of serious safety events were identified: patient care management, procedural errors, and product or device errors. Contributing factors included lack of situational awareness, process failures, and failure to communicate effectively.
Davidson JE, Chechel L, Chavez J, et al. Am J Crit Care. 2021;30(5):375-384.
Nurses play a critical role in ensuring patient safety. Following the Joint Commission’s revised standards for titration of continuous intravenous medications, 730 nurses were surveyed about their experiences. Based on 159 comments, two overarching themes were identified: harms (e.g., erosion of workplace wellness, moral dilemma, patient safety) and professionalism (e.g., autonomy, nurse proficiency).
Siebert JN, Bloudeau L, Combescure C, et al. JAMA Netw Open. 2021;4(8):e2123007.
Medication errors are common in pediatric patients who require care from emergency medical services. This randomized trial measured the impact of a mobile app in reducing medication errors during simulated pediatric out-of-hospital cardiac arrest scenarios. Advanced paramedics were exposed to a standardized video simulation of an 18-month of child with cardiac arrest and tested on sequential preparations of intravenous emergency drugs of varying degrees of difficulty with or without mobile app support. Compared with conventional drug preparation methods, use of the mobile app significantly decreased the rate of medication errors and time to drug delivery.
Siebert JN, Bloudeau L, Combescure C, et al. JAMA Netw Open. 2021;4(8):e2123007.
Medication errors are common in pediatric patients who require care from emergency medical services. This randomized trial measured the impact of a mobile app in reducing medication errors during simulated pediatric out-of-hospital cardiac arrest scenarios. Advanced paramedics were exposed to a standardized video simulation of an 18-month of child with cardiac arrest and tested on sequential preparations of intravenous emergency drugs of varying degrees of difficulty with or without mobile app support. Compared with conventional drug preparation methods, use of the mobile app significantly decreased the rate of medication errors and time to drug delivery.
Khawagi WY, Steinke DT, Carr MJ, et al. BMJ Qual Saf. 2021;Epub Aug 27.
Patient safety indicators (PSIs) can be used to identify potential patient safety hazards. Researchers used the Clinical Practice Research Datalink GOLD database to examine prevalence, variation, and patient- and practice-level risk factors for 22 mental health-related PSIs for medication prescribing and monitoring in primary care. The authors found that potentially inappropriate prescribing and inadequate medication monitoring commonly affected patients with mental illness in primary care.
Burrus S, Hall M, Tooley E, et al. Pediatrics. 2021;148(3):e2020030346.
Based on analysis of four years of data submitted to the Child Health Patient Safety Organization (CHILDPSO), researchers sought to identify types of serious safety events and contributing factors. Three main groups of serious safety events were identified: patient care management, procedural errors, and product or device errors. Contributing factors included lack of situational awareness, process failures, and failure to communicate effectively.
Pilosof NP, Barrett M, Oborn E, et al. Int J Environ Res Public Health. 2021;18(16):8391.
The COVID-19 pandemic has led to dramatic changes in healthcare delivery. Based on semi-structured interviews and direct observations, researchers evaluated the impact of a new model of remote inpatient care using telemedicine technologies in response to the pandemic. Intensive care and internal medicine units were divided into contaminated and clean zones and an integrated control room with audio-visual technologies allowed for remote supervision, communication, and support. The authors conclude that this model can increase flexibility in staffing via remote consultations and allow staff to supervise and monitor more patients without compromising patient and staff safety.
Fenton SH, Giannangelo KL, Stanfill MH. J Am Med Inform Assoc. 2021;Epub Sep 3.
The World Health Organization (WHO) released the International Classification of Diseases, 11th Revision (ICD-11) in 2018. In addition to the medical entities such as disease and injury, it contains a second component, the ICD-11 Mortality and Morbidity Statistics (MMS) linearization. The authors evaluated whether the ICD-11 MMS is appropriate for use in patient safety and quality or if a USA-specific clinical modification is necessary. 
Jagneaux T, Caffery TS, Musso MW, et al. J Patient Saf. 2021;17(6):425-429.
Emergency and internal medicine residents attended a course on central venous access that included lectures, videos, and simulation using a task trainer. Comparison of pre- and post-training evaluation demonstrated significant improvement in knowledge, confidence, and procedural skills.
van der Zanden M, de Kok L, Nelen WLDM, et al. Diagnosis (Berl). 2021;8(3):333-339.
Endometriosis is a common clinical condition that is often subject to missed or delayed diagnosis. This qualitative study explored patients’ perspectives on the diagnostic process of endometriosis. Findings suggest that the diagnosis of endometriosis is hindered by delayed consultation, inadequate understanding and appraisal of symptoms by general practitioners, and inadequate communication between patients and providers.
Davidson JE, Chechel L, Chavez J, et al. Am J Crit Care. 2021;30(5):375-384.
Nurses play a critical role in ensuring patient safety. Following the Joint Commission’s revised standards for titration of continuous intravenous medications, 730 nurses were surveyed about their experiences. Based on 159 comments, two overarching themes were identified: harms (e.g., erosion of workplace wellness, moral dilemma, patient safety) and professionalism (e.g., autonomy, nurse proficiency).
Mirarchi FL, Cammarata C, Cooney TE, et al. J Patient Saf. 2021;17(6):458-466.
Prior research found significant confusion among physicians in understanding Physician Orders for Life-Sustaining Treatment (POLST) documents, which can lead to errors. This study found that emergency medical services (EMS) personnel did not exhibit adequate understanding of all POLST or living will documents either. The researchers propose that patient video messaging can increase clarity about treatment, and preserve patient safety and autonomy.
Preston-Suni K, Celedon MA, Cordasco’s KM. Jt Comm J Qual Patient Saf. 2021;47(10):673-676.
Presenteeism among healthcare workers – continuing to work while sick – has been attributed to various cultural and system factors, such as fear of failing colleagues or patients. This commentary discusses the patient safety and ethical considerations of presenteeism during the COVID-19 pandemic
Cohen JB, Patel SY. Anesth Analg. 2021;133(3):816-820.
Designated safety leadership roles are situated to direct and sustain organizational safety progress. This commentary describes an anesthesiology safety officer function and how it is positioned to motivate staff safety behaviors and support engagement during project challenges.
Korenstein D, Harris RP, Elshaug AG, et al. J Gen Intern Med. 2021;36(7):2105-2110.
Provider and patient underestimation of harms of tests and treatments may lead to over treatment. This article presents seven domains of harm of tests and treatment which warrant comprehensive research: (1) physical impairment, (2) psychological distress, (3) social disruption, (4) disruption in connection to healthcare, (5) labeling, (6) financial impact, and (7) treatment burden. Research is especially important in vulnerable patient populations.
O’Connor P, Madden C, O’Dowd E, et al. Int J Qual Health Care. 2021;33(3):mzab117.
There are many challenges associated with detecting and measuring patient safety events. This meta-review provides an overview of approaches to measuring and monitoring safety in primary care. The authors suggest that instead of developing new methods for measuring and monitoring safety, researchers should focus on expanding the generalizability and comparability of existing methods, many of which are readily available, quick to administer, do not require external involvement, and are inexpensive.
Pring ET, Malietzis G, Kendall SWH, et al. Int J Surg. 2021;91:105987.
This literature review summarizes approaches to crisis management used by non-healthcare institutions (e.g., private businesses, large military organizations) in response to the COVID-19 pandemic and how healthcare organizations – particularly the surgical community – can leverage these approaches in operational planning and crisis management.
Newman B, Joseph K, Chauhan A, et al. Health Expect. 2021;Epub Aug 26.
Patients and families are essential partners in identifying and preventing safety events. This systematic review characterizes patient engagement along a continuum of engagement that includes consultation (e.g., patients are invited to provide input about a specific safety issue), involvement (e.g., patients are asked about their preferences/concerns and given the opportunity to engage with practitioners about a specific issue), and partnership/leadership (e.g., patients ‘work’ with practitioners to improve the safety of their care, often using tools designed to empower patients to alert practitioners to concerns).
Casey T, Turner N, Hu X, et al. J Safety Res. 2021;78:303-313.
Many factors influence the success of implementation and sustainment of patient safety interventions. Through a review of 38 research articles about safety training, researchers were able to develop a theoretical framework integrating safety training engagement and application of learned skills. They discuss individual, organizational, and contextual factors that influence safety training engagement and application.
No results.
Newspaper/Magazine Article

Ellis NT, Broaddus A. CNN. August 25, 2021. 

Maternal safety is an ongoing challenge worldwide. This news feature examines how the COVID pandemic has revealed disparities and implicit biases that impact the maternal care of black women. The stories shared highlight experiences of mothers with preventable pregnancy-related complications.

Agency for Healthcare Quality and Research. Fed Register. August 31, 2021;86:48703-48705.

This announcement calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Ambulatory Surgery Center Survey on Patient Safety Culture Database data collection process. The comment period closes September 30, 2021.

Pasztor A. Wall Street Journal. September 2, 2021.

Aviation continues to serve as an exemplar for healthcare safety efforts. This story highlights work toward the development of a National Patient Safety Board for medicine to establish a neutral centralized body to examine errors and share improvements driven by a robust self-reporting culture similar to that in commercial aviation.

Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.

Organizational assessments often provide insights that address overarching quality and safety challenges. This extensive inspection report shares findings from inspections of 36 Veterans Health Administration care facilities. Recommendations drawn from the analysis call for improvements in suicide death review, root cause analysis result application, and safety committee action item implementation.

This Month’s WebM&Ms

WebM&M Cases
Spotlight Case
Florence Tan, PharmD, Karnjit Johl, MD and Mariya Kotova, PharmD |
This case describes multiple emergency department (ED) encounters and hospitalizations experienced by a middle-aged woman with sickle cell crisis and a past history of multiple, long admissions related to her sickle cell disease. The multiple encounters highlight the challenges of opioid prescribing for patients with chronic, non-cancer pain. The commentary discusses the limitations of prescription drug monitoring program (PDMP) data for patients with chronic pain, challenges in opioid dose conversions, and increasing patient safety through safe medication prescribing and thorough medication reconciliation.
WebM&M Cases
Spotlight Case
Linnea Lantz, DO, Joseph Yoon, MD, and David Barnes, MD, FACEP |
A 44-year-old man presented to his primary care physician (PCP) with complaints of new onset headache, photophobia, and upper respiratory tract infections. He had a recent history of interferon treatment for Hepatitis C infection and a remote history of cervical spine surgery requiring permanent spinal hardware. On physical examination, his neck was tender, but he had no neurologic abnormalities. He was sent home from the clinic with advice to take over-the-counter analgesics. Over the next several days, the patient was evaluated for the same or similar symptoms again by his PCP and was seen by the emergency department and urgent care clinics before being admitted to the hospital; however, he was misdiagnosed with Staphylococcal meningitis, and it was not until his third inpatient day when cervical magnetic resonance imaging (MRI) showed a spinal epidural abscess. The commentary discusses the multiple factors leading to erroneous interpretation tests for spinal epidural abscess and the importance of broadening differentials and avoiding premature closure during diagnosis.
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.
Stay Updated!
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!