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September 29, 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

Becker C, Zumbrunn S, Beck K, et al. JAMA Netw Open. 2021;4(8):e2119346.
Discharge from the hospital represents a vulnerable time for patients. This systematic review assessed the impact of discharge communication on hospital readmissions, adherence to treatment regimen, patient satisfaction, mortality, and emergency department visits 30 days after hospital discharge. Findings suggest that improved communication at discharge reduced 30-day hospital readmissions and increased adherence to treatment regimen.
Sauro KM, Machan M, Whalen-Browne L, et al. J Patient Saf. 2021;Epub Sep 2.
Hospital adverse events are common and can contribute to serious patient harm. This systematic review included 94 studies (representing 590 million admissions from 25 countries) examining trends in hospital adverse events from 1961 to 2014. Findings indicate that hospital adverse events have increased over time and that over half are considered preventable.
Sood N, Lee RE, To JK, et al. Birth. 2021;Epub Sep 8.
Cesarean delivery can contribute to increased maternal morbidity. This retrospective study found that the introduction of a hospital-wide perioperative bundle significantly reduced surgical site infection rates. The perioperative bundle consisted of five elements (1) an antibiotic protocol, (2) preoperative warming and intraoperative maintenance of normal temperature, (3) standardized surgical preparation for each patient, (4) use of standardized fascial closure trays, and (5) standardized intraoperative application of wound dressing. 
Leggat SG, Balding C, Bish M. J Health Org Manag. 2021;35(5):550-560.
Hospital leaders are essential partners to help establish and sustain a culture of safety. This longitudinal study of Australian hospitals found that hospital leadership and clinical leaders primarily relied on staff to ensure patient safety, rather than relying on systems and processes to prevent errors.
Arntson E, Dimick JB, Nuliyalu U, et al. Ann Surg. 2021;274(4):e301-e307.
Hospital-acquired conditions (HACs) are thought to be preventable, and the Centers for Medicare & Medicaid Services (CMS) reduce payments to hospitals with the highest rates of these conditions through its Hospital-Acquired Condition Reduction Program (HACRP). This study evaluated surgical HACs at three timepoints: before Affordable Care Act (ACA) implementation, after ACA implementation, and after HACRP. While the number of HACs continued to decline after implementation of HACRP, it did not affect 30-day mortality.
Michelson KA, Reeves SD, Grubenhoff JA, et al. JAMA Netw Open. 2021;4(8):e2122248.
Diagnostic errors, including delayed diagnoses, continue to be a patient safety concern. This case-control study of children treated at five pediatric emergency departments explored the preventability of delayed diagnosis of pediatric appendicitis and associated outcomes. Researchers estimated that 23% of delayed diagnosis cases were likely to be preventable and that delayed diagnosis led to longer hospital length of stay, higher perforation rates, and additional surgical procedures.
Sood N, Lee RE, To JK, et al. Birth. 2021;Epub Sep 8.
Cesarean delivery can contribute to increased maternal morbidity. This retrospective study found that the introduction of a hospital-wide perioperative bundle significantly reduced surgical site infection rates. The perioperative bundle consisted of five elements (1) an antibiotic protocol, (2) preoperative warming and intraoperative maintenance of normal temperature, (3) standardized surgical preparation for each patient, (4) use of standardized fascial closure trays, and (5) standardized intraoperative application of wound dressing. 
Buljac-Samardzic M, Dekker-van Doorn C, van Wijngaarden JDH. J Patient Saf. 2021;17(7):490-496.
Emotional exhaustion and burnout among healthcare workers can jeopardize patient safety. This survey of caregivers from two long-term care organizations found that psychological detachment – the ability to separate oneself from the job and focusing on other areas of life – positively affects patient safety and may contribute to less burnout.
Kim S, Goelz L, Münn F, et al. BMC Musculoskelet Disord. 2021;22(1):589.
Late diagnosis of upper extremity fractures can lead to delays in treatment. When two radiologists reviewed whole-body CT scans, each missed known fractures and identified previously unknown fractures. Slice thickness was not significantly associated with missed fractures; however, missed and late diagnosis occurred more often between the hours of 5pm and 1am.
Dunbar NM, Delaney M, Murphy MF, et al. Transfusion. 2021;61(9):2601-2610.
Transfusion errors can have serious consequences. This study compared wrong blood in tube (WBIT) errors in 9 countries across three settings: emergency department, inpatient, and outpatient. Results show emergency department WBIT errors were significantly higher in emergency departments, and that electronic positive patient identification (ePPID) significantly reduced WBIT errors in the emergency department, but not in inpatient or outpatient wards.
Grabinski ZG, Babineau J, Jamal N, et al. Jt Comm J Qual Patient Saf. 2021;Epub Aug 11.
Incident reporting and analysis can lead to improvements in patient safety. This study analyzed incident reports regarding unsafe conditions (UC) in one academic women and children’s hospital. The majority of UCs were equipment and medication issues, and most had one or more contributing factors.
Osei-Poku G, Szczerepa O, Potter A, et al. Patient Safety. 2021;3(3):6-17.
This mixed-methods study examined the experiences of home healthcare workers in Massachusetts during the COVID-19 pandemic. Participating home care workers noted that the lack of necessary resources (e.g., PPE, testing) and insufficient guidance specific to home care settings made their working conditions feel unsafe.
Martin GP, Chew S, Dixon-Woods M. Soc Sci Med. 2021;287:114375.
Engaging patients and families in patient safety efforts and encouraging them to speak up about concerns is an ongoing healthcare priority. Based on narrative interviews with people raising and responding to concerns and complaints in six English National Health Service (NHS) organizations, this study explored how substandard responses to concerns and complaints can lead to organizational failures.
Ellis R, Hardie JA, Summerton DJ, et al. Surg. 2021;59(7):752-756.
Many non-urgent, non-cancer surgeries were postponed or canceled during COVID-19 surges resulting in a potential loss of surgeons’ “currency”. This commentary discusses the benefits of, and barriers to, dual surgeon operating as a way to increase currency as elective surgeries are resumed.
Sauro KM, Machan M, Whalen-Browne L, et al. J Patient Saf. 2021;Epub Sep 2.
Hospital adverse events are common and can contribute to serious patient harm. This systematic review included 94 studies (representing 590 million admissions from 25 countries) examining trends in hospital adverse events from 1961 to 2014. Findings indicate that hospital adverse events have increased over time and that over half are considered preventable.
Becker C, Zumbrunn S, Beck K, et al. JAMA Netw Open. 2021;4(8):e2119346.
Discharge from the hospital represents a vulnerable time for patients. This systematic review assessed the impact of discharge communication on hospital readmissions, adherence to treatment regimen, patient satisfaction, mortality, and emergency department visits 30 days after hospital discharge. Findings suggest that improved communication at discharge reduced 30-day hospital readmissions and increased adherence to treatment regimen.
Koeck JA, Young NJ, Kontny U, et al. Front Pediatr. 2021;9:633064.
Medication safety in children is a patient safety priority. This systematic review explored interventions to reduce medication dispensing, administration, and monitoring errors in pediatric healthcare settings. The majority of identified studies used “administrative controls” to prevent errors, but those implementing higher-level interventions (such as smart pumps and mandatory barcode scanning) were more likely to result in error reduction.
Upcoming Meeting/Conference

National Academies of Sciences, Engineering, and Medicine. October 6, 2021. 10:30 AM - 5:30 PM (eastern).

Diagnostic errors remain an ongoing challenge in many medical specialties, including oncology. This workshop will review the evidence base examining challenges in cancer diagnosis, discuss suggestions for improvement in the field, and look toward a safer future for cancer patients.

Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021.

In-depth failure investigations provide improvement insights for individuals and organizations alike. This report analyzes a collection of UK National Health Service incident examinations and provides recommendations for improvement on themes related to care transitions and access, decision making, communication, and point-of-care activity.

Bever L, Chiu A. Washington Post. September 16, 2021. 

Throughout the COVID pandemic, patients have shown reluctance to seek medical care, which contributes to delayed diagnoses and treatments for non-COVID conditions. This news story suggests actions for patients to take to keep themselves safe from harm while accessing care during uncertain times.

Clark C. MedPage Today. September 14, 2021. 

Patients who have access to their records often find errors that need to be corrected. This story highlights recent US policy changes requiring patient access to their records and explores the impact that requests for changes could have on getting records fixed to ensure accurate information is available to inform future care decisions.
Tools/Toolkit

Betsy Lehman Center. September 2021.

Clinicians involved in adverse events that harm patients can struggle to come to terms with error. This toolkit is designed to assist organizations in the development of initiatives to support clinicians and staff after an adverse event. Areas of focus include leadership buy-in, policy development, and training. An implementation guide is also provided.

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.
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