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November 10, 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

Coldewey B, Diruf A, Röhrig R, et al. Appl Ergon. 2021;98:103544.
Medical devices without user-friendly interface designs may contribute to patient complications. This review explores problems in the use and design of mechanical ventilators that challenge safe use. The authors provide recommendations to product engineers to improve safe ventilator design.
Segal M, Giuffrida P, Possanza L, et al. J Behav Health Serv Res. 2021;Epub Oct 21.
Effective integration of health information systems can improve decision making and care coordination across practice settings. This article discusses action-oriented safe practice recommendations from health information technology and electronic health record experts regarding integration of behavioral health and primary care. Recommendations focus on screening (e.g., integrated screening tools and triggers in electronic health records (EHRs)), documentation (e.g., streamlining behavioral health data entry), and sharing (e.g., using portals, secure messaging, or health information exchange to share information across care environments). The article also outlines the role of health IT developers, clinicians, and healthcare organizations in supporting behavioral health integration in primary care.
Vo J, Gillman A, Mitchell K, et al. Clin J Oncol Nurs. 2021;25(5):17-24.
Racial and ethnic disparities in healthcare can affect patient safety and contribute to adverse health outcomes. This review outlines the impact of health disparities and treatment decision-making biases (implicit bias, default bias, delay discounting, and availability bias) on cancer-related adverse effects among Black cancer survivors. The authors identify several ways that nurses to help mitigate health disparity-related adverse treatment effects, such as providing culturally appropriate care; assessing patient health literacy and comprehension; educating, empowering, and advocating for patients; and adhering to evidence-based guidelines for monitoring and management of treatment-related adverse events. The authors also discuss the importance of ongoing training on the impact of structural racism, ways to mitigate its effects, and the role of research and implementation to reduce implicit bias.
Renaudin P, Coste A, Audurier Y, et al. Basic Clin Pharmacol Toxicol. 2021;Epub Sep 24.
Pharmacists play an essential role in medication safety through practices such as medication reconciliation and best possible medication history. This observational study found that 20% of patients presenting to surgical units at one French hospital over a two-month period had a medication error. Pharmacists intervened and resolved medication errors related to untreated indications, subtherapeutic dosages, and prescriptions without an indication.
Mulac A, Hagesaether E, Granas AG. J Adv Nurs. 2021;Epub Oct 12.
Medication dosing errors can lead to serious patient harm. This retrospective study found that the majority of dose calculation errors reported to the Norwegian Incident Reporting System involved intravenous administration such as intravenous morphine. These errors occurred due to lack of proper safeguards to intercept prescribing errors, stress, and bypassing double checks.
Rosenkrantz AB, Siegal D, Skillings JA, et al. J Am Coll Radiol. 2021;18(9):1310-1316.
Prior research found that cancer, infections, and vascular events (the “big three”) account for nearly half of all serious misdiagnosis-related harm identified in malpractice claims. This retrospective analysis of malpractice claims data from 2008 to 2017 found that oncology-related errors represented the largest source of radiology malpractice cases with diagnostic allegations. Imaging misinterpretation was the primary contributing factor.
Ali A, Miller MR, Cameron S, et al. Pediatr Emerg Care. 2021;Epub Oct 26.
Interhospital transfer of critical care patients presents patient safety risks. This retrospective study compared adverse event rates between pediatric patient transport both with, and without, parent or family presence. Adverse event rates were not significantly impacted by parental presence.
Silverglow A, Johansson L, Lidén E, et al. Scand J Caring Sci. 2021;Epub Aug 24.
Home care settings harbor unique patient safety challenges. This qualitative study identified three themes regarding care providers’ perceptions of providing safe care for frail older adults living at home – the role of the encounter and interaction, the responsibility of the caregiver, and the threat of insufficient organizational resources.
Hennus MP, Young JQ, Hennessy M, et al. ATS Sch. 2021;2(3):397-414.
The surge of patients during the COVID-19 pandemic forced the redeployment of non-intensive care certified staff into intensive care units (ICU). This study surveyed both intensive care (IC)-certified and non-IC-certified healthcare providers who were working in ICUs at the beginning of the pandemic. Qualitative synthesis identified five themes related to supervision; quality and safety of care; collaboration, communication, and climate; recruitment, scheduling and team composition, and; organization and facilities. The authors provide recommendations for future deployments.
Mo Y, Eyre DW, Lumley SF, et al. PLoS Med. 2021;18(10):e1003816.
Nosocomial transmission of COVID-19 is an ongoing concern given the pressures faced by hospitals and healthcare workers during the pandemic. This observational study using data from four hospitals in the United Kingdom found that patients with hospital-onset COVID-19 (compared to suspected community-acquired infections) are associated with high risk of nosocomial transmissions to other patients and healthcare workers.
Braverman A. Nurs Manage. 2021;52(9):30-34.
In high-consequence environments, differences of opinion can undermine teamwork and result in operational failure. This article discusses the application of crew resource management (CRM) to the clinical environment. The author outlines steps to translate the aviation CRM experience into the health care domain to improve communication and resolve conflicts in stressful situations.
Leibner ES, Baron EL, Shah RS, et al. J Patient Saf. 2021;Epub Sep 28.
During the first surge of the COVID-19 pandemic, a rapid redeployment of noncritical care healthcare staff was necessary to meet the unprecedented number of patients needing critical care. A New York health system developed a multidisciplinary simulation training program to prepare the redeployed staff for new roles in the intensive care unit (ICU). The training included courses on management of a patient with acute decompensation with COVID-19, critical care basics for the non-ICU provider, and manual proning of a mechanically ventilated patient.
Vo J, Gillman A, Mitchell K, et al. Clin J Oncol Nurs. 2021;25(5):17-24.
Racial and ethnic disparities in healthcare can affect patient safety and contribute to adverse health outcomes. This review outlines the impact of health disparities and treatment decision-making biases (implicit bias, default bias, delay discounting, and availability bias) on cancer-related adverse effects among Black cancer survivors. The authors identify several ways that nurses to help mitigate health disparity-related adverse treatment effects, such as providing culturally appropriate care; assessing patient health literacy and comprehension; educating, empowering, and advocating for patients; and adhering to evidence-based guidelines for monitoring and management of treatment-related adverse events. The authors also discuss the importance of ongoing training on the impact of structural racism, ways to mitigate its effects, and the role of research and implementation to reduce implicit bias.
Meyer AND, Giardina TD, Khawaja L, et al. Patient Educ Couns. 2021;104(11):2606-2615.
Diagnostic uncertainty can lead to misdiagnosis and delayed treatment. This article provides an overview of the literature on diagnosis-related uncertainty, where uncertainty occurs in the diagnostic process and outlines recommendations for managing diagnostic uncertainty.
Segal M, Giuffrida P, Possanza L, et al. J Behav Health Serv Res. 2021;Epub Oct 21.
Effective integration of health information systems can improve decision making and care coordination across practice settings. This article discusses action-oriented safe practice recommendations from health information technology and electronic health record experts regarding integration of behavioral health and primary care. Recommendations focus on screening (e.g., integrated screening tools and triggers in electronic health records (EHRs)), documentation (e.g., streamlining behavioral health data entry), and sharing (e.g., using portals, secure messaging, or health information exchange to share information across care environments). The article also outlines the role of health IT developers, clinicians, and healthcare organizations in supporting behavioral health integration in primary care.
Coldewey B, Diruf A, Röhrig R, et al. Appl Ergon. 2021;98:103544.
Medical devices without user-friendly interface designs may contribute to patient complications. This review explores problems in the use and design of mechanical ventilators that challenge safe use. The authors provide recommendations to product engineers to improve safe ventilator design.
Bernstein SL, Kelechi TJ, Catchpole K, et al. Worldviews Evid Based Nurs. 2021;Epub Sep 6.
Failure to rescue, the delayed or missed recognition of a potentially fatal complication that results in the patient’s death, is particularly tragic in obstetric care. Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, the authors describe the work system, process, and outcomes related to failure to rescue, and develop intervention theories.
Hyvämäki P, Kääriäinen M, Tuomikoski A-M, et al. J Patient Saf. 2021;Epub Aug 23.
Previous studies have demonstrated health information exchanges (HIE) can improve the quality and safety of care by improving diagnostic concordance and reducing medication errors. This review synthesizes physicians’ and nurses’ perspectives on patient safety related to use of HIE in interorganizational care transitions. Several advantages of and challenges with HIE are detailed.

Institute for Safe Medication Practices. December 7, 2021. 1:00-2:30 PM (eastern).

Medication errors happen across the continuum of surgical care. This webinar will review results of a national survey revealing front line risks in perioperative settings and recommend practices for addressing these challenges to improve medication safety.

Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 28, 2021 Publication No. NOT-HS-22-004.

Digital information tools are increasingly relied upon to assist in care communication and decision support, yet their safety hasn’t been fully examined. This announcement highlights AHRQ interest in funding research on the safe use of digital information solutions with a focus on program implementation, system design, and usability.
Special or Theme Issue

JAMA. 2021. 

Diagnostic excellence achievement is becoming a primary focus in health care. This article series covers diagnosis as it relates to the Institute of Medicine quality domains, clinical challenges, and priorities for improvement across the system.

US House of Representatives Committee on Veterans' Affairs Subcommittee on Health.  117th Cong. 1st Sess (2021).

The Veterans Health Administration is a large complex system that faces various challenges to safe care provision. At this hearing, government administrators testified on current gaps that detract from safe care in the Veteran’s health system. The experts discussed several high-profile misconduct and systemic failure incidents, suggested that the culture and leadership within the system overall enables latency of issues, and outlined actions being taken to address weaknesses.

This Month’s WebM&Ms

WebM&M Cases
Spotlight Case
Hannah Spero, MSN, APRN, Angela E. Usher, PhD, LCSW, Brian Howard MS1, and Frederick J. Meyers, MD |
A 77-year-old man was diagnosed with a rectal mass. After discussing goals of care with an oncologist, he declined surgical intervention and underwent targeted radiotherapy before being lost to follow up. The patient subsequently presented to Emergency Department after a fall at home and was found to have new metastatic lesions in both lungs and numerous enhancing lesions in the brain. Further discussions of the goals of care revealed that the patient desired to focus on comfort and on maintaining independence for as long as possible. The inpatient hospice team discussed the potential role of brain radiotherapy for palliation to meet the goal of maintaining independence. The patient successfully completed a course of central nervous system (CNS) radiation, which resulted in improved strength, energy, speech, and quality of life. This case represents a perceived delay in palliative radiation, an “error” in care. The impact of the delay was lessened by the hospice team who role modeled integration of disease directed therapy with palliative care, a departure from the historic model of separation of hospice from disease treatment. 
WebM&M Cases
Gary S. Leiserowitz, MD, MS and Herman Hedriana, MD |
A 32-year-old pregnant woman presented with prelabor rupture of membranes at 37 weeks’ gestation. During labor, the fetal heart rate dropped suddenly and the obstetric provider diagnosed umbilical cord prolapse and called for an emergency cesarean delivery. Uterine atony was noted after delivery of the placenta, which quickly responded to oxytocin bolus and uterine massage. After delivery, the patient was transferred to the post-anesthesia care unit (PACU) and monitored for 90 minutes, after which she was deemed stable, despite some abnormal vital signs. All monitor alarm functions were silenced to help the patient rest until a bed became available on the maternity floor. After another 90 minutes, the patient’s nurse discovered her unresponsive and the bedsheets were blood-soaked. A massive transfusion was ordered and uterotonic medications were administered, but vaginal bleeding continued. During an emergency laparotomy, the uterus was noted to be atonic despite uterotonic therapy, requiring an emergency hysterectomy. The commentary discusses the importance and use of early maternal warning systems, checklists and protocols to avoid poor maternal outcomes.
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.

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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