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January 12, 2022 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

Al Rowily A, Jalal Z, Price MJ, et al. Eur J Clin Pharmacol. 2022;78:623-645.
Although direct acting oral anticoagulants (DAOCs) are generally considered safer than older anticoagulants, they are still high-risk medications. This review found that between 5.3% and 37.3% of patients experienced either a prescription, administration, or dosing error. Prescribing errors constituted the majority of error types, and common causes were active failures, including wrong drug or wrong dose.
Hallvik SE, El Ibrahimi S, Johnston K, et al. Pain. 2022;163:83-90.
Opiates are a high-risk medication due to the potential for adverse events including misuse and overdose. This study examined whether dose reduction or discontinuation after high-dose chronic opioid therapy is associated with suicide, overdose, or other adverse events. In this cohort of Oregon Medicaid recipients, discontinuation increased the risk for suicide or opioid-related adverse events. Patients with stable or increasing doses had an increased risk of overdose.
Holmes J, Chipman M, Barbour T, et al. Jt Comm J Qual Patient Saf. 2022;48:12-24.
Air medical transport carries unique patient safety risks. In this study, researchers used simulation training and healthcare failure mode and effect analysis (HFMEA) to identify latent safety threats related to patient transport via helicopter. This approach identified 31 latent safety threats (18 were deemed critical) related to care coordination, facilities, equipment, and devices.
Holmes J, Chipman M, Barbour T, et al. Jt Comm J Qual Patient Saf. 2022;48:12-24.
Air medical transport carries unique patient safety risks. In this study, researchers used simulation training and healthcare failure mode and effect analysis (HFMEA) to identify latent safety threats related to patient transport via helicopter. This approach identified 31 latent safety threats (18 were deemed critical) related to care coordination, facilities, equipment, and devices.
Mazor KM, Kamineni A, Roblin DW, et al. J Patient Saf. 2021;17:e1278-e1284.
Patient engagement and encouraging speaking up can promote safety. This randomized study found that patients undergoing cancer treatment who were randomized to an active outreach program were significantly more likely to speak up and report healthcare concerns than patients in the control group.
Cooper A, Carson-Stevens A, Cooke M, et al. BMC Emerg Med. 2021;21:139.
Overcrowding in the emergency department (ED) can result in increased frequency of medication errors, in-hospital cardiac arrest, and other patient safety concerns. This study examined diagnostic errors after introducing a new healthcare service model in which emergency departments are co-located with general practitioner (GP) services. Potential priority areas for improvement include appropriate triage, diagnostic test interpretation, and communication between GP and ED services.
Hallvik SE, El Ibrahimi S, Johnston K, et al. Pain. 2022;163:83-90.
Opiates are a high-risk medication due to the potential for adverse events including misuse and overdose. This study examined whether dose reduction or discontinuation after high-dose chronic opioid therapy is associated with suicide, overdose, or other adverse events. In this cohort of Oregon Medicaid recipients, discontinuation increased the risk for suicide or opioid-related adverse events. Patients with stable or increasing doses had an increased risk of overdose.
De Angulo NR, Penwill N, Pathak PR, et al. Hosp Pediatr. 2021;Epub Dec 24.
This study explored administrator, physician, nurse, and caregiver perceptions of safety in pediatric inpatient care during the first months of the COVID-19 pandemic. Participants reported changes in workflows, discharge and transfer process, patient and family engagement, and hospital operations.
Neves AL, van Dael J, O’Brien N, et al. J Telemed Telecare. 2021;Epub Dec 12.
This survey of individuals living in the United Kingdom, Sweden, Italy, and Germany identified an increased use of virtual primary care services – such as telephone or video consultation, remote triage, and secure messaging systems – since the onset of the COVID-19 pandemic. Respondents reported that virtual technologies positively impacted multiple dimensions of care quality, including timeliness, safety, patient-centeredness, and equity.
Winning AM, Merandi J, Rausch JR, et al. J Patient Saf. 2021;17:531-540.
Healthcare professionals involved in a medical error often experience psychological distress. This article describes the validation of a revised version of the Second Victim Experience and Support Tool (SVEST-R), which was expanded to include measures of resilience and desired forms of support.
Linzer M, Neprash HT, Brown RL, et al. Ann Fam Med. 2021;19:521-526.
Using data from the Healthy Work Place trial, this study explored characteristics associated with high clinician and patient trust. Findings suggest that trust is higher when clinicians perceived their organizational cultures as emphasizing quality, communication and information, cohesiveness, and value alignment between clinicians and leaders.
Gandhi TK. Jt Comm J Qual Patient Saf. 2022;48:61-64.
Families and caregivers play an important role in ensuring patient safety. At the start of the COVID-19 pandemic and, to a lesser extent, during surges, family and caregiver visitation was severely restricted. This commentary advocates reassessing risks and benefits of restricted visitation, both during the pandemic and beyond.
Lo L, Rotteau L, Shojania KG. BMJ Open. 2021;11:e055247.
Situation, Background, Assessment, Recommendation (SBAR) is a mnemonic technique used to avoid communication failures during handoffs. This systematic review found that fidelity with SBAR is highest in classroom settings, but that studies in clinical contexts either did not achieve sufficient improvements in fidelity or did not assess fidelity.
Montero-Odasso MM, Kamkar N, Pieruccini-Faria F, et al. JAMA Netw Open. 2021;4:e2138911.
Fall prevention in healthcare settings is a patient safety priority. This systematic review found that most clinical practice guidelines provide consistent recommendations for fall prevention for older adults. Guidelines consistently recommend strategies such as risk stratification, medication review, and environment modification.
Duffy B, Miller J, Vitous CA, et al. J Patient Saf. 2021;17:e1765-e1773.
Healthcare providers are increasingly disclosing their errors to patients. This review summarizes available guidance for how and when to report other providers’ errors, particularly those outside their own facility or system. Guidelines tended to be ambiguous and restricted to incompetence.
Al Rowily A, Jalal Z, Price MJ, et al. Eur J Clin Pharmacol. 2022;78:623-645.
Although direct acting oral anticoagulants (DAOCs) are generally considered safer than older anticoagulants, they are still high-risk medications. This review found that between 5.3% and 37.3% of patients experienced either a prescription, administration, or dosing error. Prescribing errors constituted the majority of error types, and common causes were active failures, including wrong drug or wrong dose.
No results.

Institute for Safe Medication Practices. Medication Safety Alerts. January 3, 2022.

Emerging care practices can produce unsafe situations due to the newness of the approaches involved. This alert highlights safety considerations with an oral antiretroviral COVID treatment that include medication administration problems. Safety recommendations are provided for prescribers and pharmacists.
Special or Theme Issue

Dean J, Subbe C, eds. Future Healthc J. 2021;8(3):e559-e618.

Full realization of the patient voice as a resource for safety is challenging. This special section provides global perspectives examining cultural, organizational, and system-focused opportunities to fully use patient knowledge in improvement initiatives.

Newcastle upon Tyne, UK: Care Quality Commission; September 2021.

The safety of maternity care is threatened by inequity. This report analyzes a set of United Kingdom investigation reports to identify issues affecting maternity care to determine their prevalence elsewhere in the system. Problems identified include poor leadership and teamwork, as well as learning and cross-service collaboration.

Famolaro T, Hare R, Tapia A, Yount et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0004.

Ambulatory surgery centers harbor unique characteristics that affect safety culture. This analysis from the Agency for Healthcare Research and Quality (AHRQ) shares results of 235 ambulatory surgery centers (ASCs) participating in the Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey. Most respondents (92%) rated their organization as committed to learning and continuous improvement.

This Month’s WebM&Ms

WebM&M Cases
Jane L. Erb, MD, Sejal B. Shah, MD and Gordon D. Schiff, MD |
An 18-year-old man with a history of untreated depression and suicide attempts (but no history of psychiatric hospitalizations) was seen in the ED for suicidal ideation after recent gun purchase. Due to suicidal ideation, he was placed on safety hold and a psychiatric consultation was requested. The psychiatry team recommended discharge with outpatient therapy; he was discharged with outpatient resources, the crisis hotline phone number, and strict return precautions. After two encounters with his primary care provider and another visit to the ED for suicidal ideation, the patient was found with a loaded gun in a hotel room. He was taken to the ED for a third time, where has was evaluated and involuntarily admitted to an inpatient psychiatric hospital for five weeks.  He was ultimately discharged with a diagnosis of “Bipolar 1 – moderate-severe with mixed features.” The commentary discusses the challenges of screening for suicide risk and the importance of continuity of care for patients at risk of self-harm and suicide.
WebM&M Cases
Candice Sauder, MD, MS, MEd, FACS and Kara T Kleber, MD, MA |
A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several different providers (pre-operative nurse, resident physician, attending physician, and anethesiology team) to help prepare her for the procedure. In the OR, the surgical team performed two separate time-outs while the patient was being prepped, placed under general anesthesia, and draped. After the attending physician began operating, she realized that no radiotracer dye had been injected for the SNLB – a key process step that was supposed to have occurred prior to the surgery. The nuclear medicine team never saw the patient preoperatively, and none of the staff members or teams realized this until the patient was under general anesthesia with an open incision. The commentary discusses how pre-operative checklist protocols can help multidisciplinary teams avoid communication errors and reduce opportunities for adverse events.
WebM&M Cases
Gary Raff, MD, and Brian Goudy, MD |
This case involves a 2-year-old girl with acute myelogenous leukemia and thrombocytopenia (platelet count 26,000 per microliter) who underwent implantation of a central venous catheter with a subcutaneous port. The anesthetist asked the surgeon to order a platelet transfusion to increase the child’s platelet count to above 50,000 per microliter. In the post-anesthesia care unit, the patient’s arterial blood pressure started fluctuating and she developed cardiac arrest. A “code blue” was called and the child was successfully resuscitated after insertion of a thoracostomy drainage (chest) tube. Unfortunately, the surgeon damaged an intercostal artery when he inserted the chest tube emergently, which caused further bleeding and two additional episodes of PEA arrest. This commentary addresses the importance of mitigating risk during procedures, balancing education of proceduralist trainees with risk to the patient, and prompt review of diagnostic studies by qualified individuals to identify serious complications.

This Month’s Perspectives

Interview
Patient Safety Organizations (PSOs) are organizations dedicated to improving patient safety and healthcare quality that serve to collect and analyze data voluntarily reported by healthcare providers to promote learning. Federal confidentiality and privilege protections apply to certain information (defined as “patient safety work product”) developed when a healthcare provider works with a federally listed PSO under the Patient Safety and Quality Improvement Act of 2005 and its implementing regulation. AHRQ is responsible for the administration and enforcement of the PSO listing process. Based on their presentations at an AHRQ annual meeting, we spoke with representatives from two PSOs, Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO about how the unique circumstances surrounding care during the COVID-19 pandemic impacted patient safety risks in both COVID-19 and non-COVID-19 patients.
Perspective
This piece discusses patient safety challenges that arose as a result of the unique care circumstances surrounding the COVID-19 pandemic, particularly at the height of the pandemic in 2020. 
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