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October 13, 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

Lafferty M, Harrod M, Krein SL, et al. J Am Med Inform Assoc. 2021;Epub Sep 28.
Use of one-way communication technologies, such as pagers, in hospitals have led to workarounds to improve communication. Through observation, shadowing, interviews, and focus groups with nurses and physicians, this study describes antecedents, types, and effects of workarounds and their potential impact on patient safety.
Pinnock R, Ritchie D, Gallagher S, et al. Adv Health Sci Educ Theory Pract. 2021;26(3):785-809.
Cognition is a recognized human factor that can contribute to medical error. This systematic review explored whether mindful practice can improve diagnosis in healthcare. Of the 33 included studies, the majority were non-empirical; however, the authors tentatively conclude that mindful practice may be a promising method to improve diagnostic accuracy and reduce error.
Zaheer S, Ginsburg LR, Wong HJ, et al. BMC Nurs. 2021;20(1):134.
A culture of safety is essential to reducing medical errors and improving patient safety. In this mixed-methods study, researchers found that acute care nurses’ perceptions of senior leadership, teamwork, and turnover intention were associated with perceived patient safety.
Dornan T, Lee C, Findlay-White F, et al. Med Teach. 2021;Epub Aug 11.
Health profession students are required to demonstrate competence in a variety of areas related to safe patient care. This article puts forth a recommendation to move beyond core competencies to improve patient safety and clinicians’ mutual safety.
Zaheer S, Ginsburg LR, Wong HJ, et al. BMC Nurs. 2021;20(1):134.
A culture of safety is essential to reducing medical errors and improving patient safety. In this mixed-methods study, researchers found that acute care nurses’ perceptions of senior leadership, teamwork, and turnover intention were associated with perceived patient safety.
Khidir H, McWilliams JM, O’Malley AJ, et al. JAMA Netw Open. 2021;4(9):e2125193.
While racial, ethnic, and gender biases have been widely documented at the system level, it has not been well documented at the individual physician level. This analysis of 4.5 million emergency department visits in the US showed variation in hospital admission rates among physicians, but an individual physician’s propensity to admit patients did not vary by patient sociodemographic group.
Schaffer AC, Babayan A, Einbinder JS, et al. Obstet Gynecol. 2021;138(2):246-252.
Adverse events in obstetrics threaten the safety of both maternal and infant patients. This study identified a significant reduction in malpractice claims among obstetrician-gynecologists after participation in simulation training focused on team training and crisis management.
Klatt TE, Sachs JF, Huang C-C, et al. Jt Comm J Qual Patient Saf. 2021;47(12):759-767.
This article describes the implementation of a peer support program for “second victims” in a US healthcare system. Following training, peer supporters assisted at-risk colleagues, raised awareness of second victim syndrome, and recruited others for training. The effectiveness of the training was assessed using the Second Victim Experience Support Tool. The most common event supported was inability to stop the progress of a medical condition, including COVID-19.
Berdot S, Vilfaillot A, Bézie Y, et al. BMC Nurs. 2021;20(1):153.
Interruptions have been identified as a common source of medication errors. In this study of the effectiveness of a “do not interrupt” vest worn by nurses from medication preparation to administration, neither medication administration error or interruption rates improved.
Volkar JK, Phrampus P, English D, et al. J Patient Saf. 2021;17(7):e689-e693.
The goal of peer review is to provide clinicians with the opportunity to learn from errors. A multidisciplinary panel at one academic medical center established a new approach for physician peer review which incorporated a protected electronic portal for communication and engagement and a Just Culture peer review algorithm to identify opportunities for system improvements. The new approach decreased the average time necessary for full case review and increased provider engagement.
Lafferty M, Harrod M, Krein SL, et al. J Am Med Inform Assoc. 2021;Epub Sep 28.
Use of one-way communication technologies, such as pagers, in hospitals have led to workarounds to improve communication. Through observation, shadowing, interviews, and focus groups with nurses and physicians, this study describes antecedents, types, and effects of workarounds and their potential impact on patient safety.
Montaleytang M, Correard F, Spiteri C, et al. Int J Clin Pharm. 2021;43(5):1183-1190.
Previous studies have found that discrepancies between patients’ medication lists and medications they are actually taking are common. This study found that sharing the results of medication reconciliation performed at admission and discharge with patients’ community care providers led to a decrease in medication discrepancies.
Lasser EC, Heughan JA-A, Lai AY, et al. Curr Med Res Opin. 2021;Epub Sep 8.
Patient-centered medical homes (PCMHs) are designed to be team-based, coordinated, accessible primary health care. This qualitative study explored patient perceptions about safety in PCMHs. Identified themes important to patient safety include communication with and between clinicians and trust in the care team, including being heard, respected, and treated as a whole person.
Slikkerveer M, van de Plas A, Driessen JHM, et al. J Patient Saf. 2021;17(7):e587-e592.
Anticoagulants, such as low-molecular-weight heparin (LMWH), are known to be high-risk for adverse drug events. This cross-sectional study identified prescribing errors – primarily lack of dosage adjustment for body weight and/or renal function – among one-third of LMWH users admitted to one hospital over a five-month period.
Huynh I, Rajendran T. BMJ Open Qual. 2021;10(3):e001363.
Unintentional therapeutic duplication can lead to life-threatening complications. As part of a quality improvement project on a surgical ward, staff were educated about the risks of therapeutic duplication and strategies to decrease it. After one month of education and reminders, the rate of therapeutic duplication decreased by more than half.
Hendrickx I, Voets T, van Dyk P, et al. J Med Internet Res. 2021;23(7):e19064.
Prioritization of patient complaints allows inspectors to follow up more quickly on those that pose the most severe safety risk. Using text mining and sentiment analysis, more than 22,000 patient complaints were assigned a severity category. The ‘bag-of-words representation’ was most successful for severity predicting and could be used to triage patient complaints.
Taylor E, Hignett S. Int J Environ Res Public Health. 2021;18(15):7780.
Informed environmental features, such as the built environment, can improve safety outcomes. The authors propose a theoretic model and matrix (DEEP SCOPE; DEsigning with Ergonomic Principles – Safety as Complexity of the Organization, People, and Environment) intended to synthesize design interventions into a systems-based model using the principles of human factors and ergonomics.
Pinnock R, Ritchie D, Gallagher S, et al. Adv Health Sci Educ Theory Pract. 2021;26(3):785-809.
Cognition is a recognized human factor that can contribute to medical error. This systematic review explored whether mindful practice can improve diagnosis in healthcare. Of the 33 included studies, the majority were non-empirical; however, the authors tentatively conclude that mindful practice may be a promising method to improve diagnostic accuracy and reduce error.

Institute for Safe Medication Practices. October 26, 2021.

Community pharmacies encounter a variety of challenges to medication safety. This webinar focused on high-alert medications and discuss unreliable medication delivery methods. The session also covered vaccination errors and how to prevent them.

Collaborative for Accountability and Improvement. October 21, 2021. 

Communication-and-resolution program (CRP) initiatives are a valuable strategy for improving support and transparency after an adverse incident. This webinar discussed how patients and families feel about support mechanisms after they have experienced medical error, if they were involved in a CRP process and the types of information they required after a harmful incident.

Zirger JM, Centers for Disease Control and Prevention. Fed Register. September 27, 2021;86:53309-53312.

Tracking healthcare-associated infection (HAI) data aids in national, regional, and organizational design of HAI improvement efforts. This notice calls for public comment on the continuation of the National Healthcare Safety Network HAI information collection process. The comment period closes November 26, 2021.

Graber ML, Schrandt S. Evanston, IL:  Society to Improve Diagnosis in Medicine;  September 8, 2021. 

This report summarizes the results of a project that examined how the literature and various stakeholders consider challenges and opportunities for improving diagnosis during telemedicine interactions. Both areas of concern and potential were highlighted to engage researchers, educators, and clinicians in the implementation and use of telediagnosis that is safe and of high-value for patients and families.

Bean M, Masson G. Becker's Hospital Review. October 4, 2021.

Staffing shortages can impact the safety of care by enabling burnout, care omission, and staff attrition. This article discusses how the COVID-19 pandemic has necessitated an examination of how staffing challenges affect areas such as diagnosis, infection control, and organizational patient safety focus.

This Month’s WebM&Ms

WebM&M Cases
Marissa G. Vadi, MD, MPH, and Mathew R. Malkin, MD |
A 6-week-old infant underwent a craniotomy and excision of abnormal brain tissue for treatment of hemimegalencephaly and epilepsy. A right femoral central venous catheter and an arterial catheter were inserted, as well as 22-gauge intravenous catheter inserted into the external jugular vein, which was covered with surgical drapes.  During the surgical procedure, the neurosurgeon adjusted the patient’s head, displacing the external jugular intravenous catheter into the subcutaneous tissue.  The catheter’s dislodgment went unnoticed due to its position underneath the surgical drapes. The commentary discusses the importance intraoperative monitoring of intravenous catheters and the use of surgical safety checklists to improve communication and prevent surgical complications.
WebM&M Cases
Robin Aldwinckle, MD and Edmund Florendo, MD |
A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution. Shortly after receiving sedation, the patient became unresponsive, and a code was called. The commentary addresses the challenges of drug dilution and strategies to reduce dilutional errors and prioritize patient safety.
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.

This Month’s Perspectives

Gina Luchen
Interview
Georgia Galanou Luchen, Pharm. D., is the Director of Member Relations at the American Society of Health-System Pharmacists (ASHP). In this role, she leads initiatives related to community pharmacy practitioners and their impact throughout the care continuum. We spoke with her about different types of community pharmacists and the role they play in ensuring patient safety. 
Alison Stuebe photo
Interview
Alison Stuebe, MD, MSc, is a professor and Division Director for Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology at the University of North Carolina (UNC) at Chapel Hill and the co-director of the Collaborative for Maternal and Infant Health. Kristin Tully, PhD, is a research assistant professor in the Department of Obstetrics and Gynecology at UNC Chapel Hill and a member of the Collaborative for Maternal and Infant Health. We spoke with them about their work in maternal and infant care and what they are discovering about equitable care and its impact on patient safety.
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