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February 2, 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

Batra EK, Lewis ML, Saravana D, et al. Pediatrics. 2021;148:e2020033704.
Safety bundles are known to improve clinician adherence to guidelines and improve patient safety. This children’s hospital implemented a safe sleep bundle in all departments to reduce sudden unexpected infant deaths. Overall compliance with safe sleep guidelines increased from 9% to 72%. Three individual components also improved (head of bed flat, sleep space free of extra items, and caregiver education completed); one measure, centerline for infant in supine position, remained stable. The safe sleep bundle was shown to be effective in improving infant sleep environments.
Bourne RS, Jennings JK, Panagioti M, et al. BMJ Qual Saf. 2022;Epub Jan 18.
Patients transferring from the intensive care unit (ICU) to the hospital ward may experience medication errors. This systematic review examined medication-related interventions on the impact of medication errors in ICU patients transferring to the hospital ward. Seventeen studies were included with five identified intervention components. Multi-component studies based on staff education and guidelines were effective at achieving almost four times more deprescribing on inappropriate medications by the time of discharge. Recommendations for improving transfers are included.
Sujan M, Bilbro N, Ross A, et al. Appl Ergon. 2022;98:103608.
Failure to rescue refers to delayed or missed recognition of a potentially fatal complication that results in a patient’s death. This single-center study sought to more effectively manage deteriorating patients after emergency surgery and reduce failure to rescue rates. Researchers used the functional resonance analysis method (FRAM) to develop recommendations for strengthening organizational resilience. Recommendations included improving team communication, organizational learning, and relationships.
Kuhn J, van den Berg P, Mamede S, et al. Adv Health Sci Edu. 2022;27:189-200.
Diagnostic calibration is the relationship between individual confidence in diagnostic decision making and diagnostic accuracy, and it can lead to diagnostic error or overtesting. This study investigated whether feedback would improve general-practice residents’ diagnostic calibration on difficult cases. Results did not show that feedback on diagnostic performance improved diagnostic calibration.
Moore MR, Mitchell SJ, Weller JM, et al. Anaesthesia. 2021;77:185-195.
Surgical safety checklists (SSCs) have been shown to improve patient outcomes and reduce complications. In this study, postoperative mortality and increased days alive and out of hospital were measures for surgical patients in the 18-month period prior to implementation of the SSC and the 18-month period following implementation. Changes in mortality and days alive and out of hospital during these time periods were indistinguishable from longer-term trends. Researchers noted Māori patients had worse outcomes than non-Māori patients.
Sujan M, Bilbro N, Ross A, et al. Appl Ergon. 2022;98:103608.
Failure to rescue refers to delayed or missed recognition of a potentially fatal complication that results in a patient’s death. This single-center study sought to more effectively manage deteriorating patients after emergency surgery and reduce failure to rescue rates. Researchers used the functional resonance analysis method (FRAM) to develop recommendations for strengthening organizational resilience. Recommendations included improving team communication, organizational learning, and relationships.
Rivera-Chiauzzi EY, Smith HA, Moore-Murray T, et al. J Patient Saf. 2022;18:e308-e314.
Peer support programs are increasingly used to support clinicians involved in adverse events. This evaluation found that a structured peer support program for providers involved in obstetric adverse events can effectively support providers in short periods of time (for example, 92% of participants did not need follow-up after second peer support contact) and can be initiated with limited resources.
Wells HJ, Raithatha M, Elhag S, et al. BMJ Open Qual. 2022;11:e001551.
Use of personal protective equipment is necessary to reduce the spread of infectious diseases, such as COVID-19, in healthcare settings. The alertness levels of ICU staff who regularly wore full personal protective equipment (FPPE), i.e., respirator mask, body covering suit, visor, gloves, and hat, were tested when not wearing FPPE and after two hours wearing FPPE. Results show health care worker alertness can be negatively impacted by wearing FPPE for as little as two hours.
Batra EK, Lewis ML, Saravana D, et al. Pediatrics. 2021;148:e2020033704.
Safety bundles are known to improve clinician adherence to guidelines and improve patient safety. This children’s hospital implemented a safe sleep bundle in all departments to reduce sudden unexpected infant deaths. Overall compliance with safe sleep guidelines increased from 9% to 72%. Three individual components also improved (head of bed flat, sleep space free of extra items, and caregiver education completed); one measure, centerline for infant in supine position, remained stable. The safe sleep bundle was shown to be effective in improving infant sleep environments.
Kuhn J, van den Berg P, Mamede S, et al. Adv Health Sci Edu. 2022;27:189-200.
Diagnostic calibration is the relationship between individual confidence in diagnostic decision making and diagnostic accuracy, and it can lead to diagnostic error or overtesting. This study investigated whether feedback would improve general-practice residents’ diagnostic calibration on difficult cases. Results did not show that feedback on diagnostic performance improved diagnostic calibration.
Rajan SS, Baldwin JL, Giardina TD, et al. J Patient Saf. 2022;18:e262-e266.
Radiofrequency identification (RFID) technology has been most commonly used in perioperative settings to improve patient safety. This study explored whether RFID technology can improve process measures in laboratory settings, such as order tracking, specimen processing, and test result communication. Findings indicate that RFID-tracked orders were more likely to have completed testing process milestones and were completed more quickly.
McDonald EG, Wu PE, Rashidi B, et al. JAMA Intern Med. 2022;182:265-273.
Deprescribing is one intervention to reduce the risk of adverse drug events, particularly in older adults and people taking five or more medications. In this cluster randomized trial, older adults (≥65 years) taking at least five medications at hospital admission were randomly assigned to intervention (personalized reports of deprescribing opportunities) or control. Despite an increase in deprescribing in both groups, there was no difference in adverse drug events or adverse drug withdrawal events.
Turner A, Morris R, Rakhra D, et al. Br J Gen Pract. 2021;72:e128-e137.
The UK’s National Health Service (NHS) is increasingly using digital technology to deliver care. Researchers interviewed 19 patients and 18 general practice staff about their experiences with one of the NHS’s digital tools, online (asynchronous) consultations. Unintended consequences related to access to and efficiency of care are discussed.  
Patel S, Pierce L, Jones M, et al. Jt Comm J Qual Patient Saf. 2022;48:165-172.
Performance feedback is an essential component of patient safety and quality improvement. In this participatory study, researchers engaged hospitalists in design sessions and surveys to develop a performance dashboard and feedback system. Physicians preferred that the dashboard be used to aid in clinical practice improvement as part of a non-punitive system.
DeCherrie LV, Leff B, Levine DM, et al. Jt Comm J Qual Patient Saf. 2022;48:180-184.
Hospital at Home (HAH), in which patients receive hospital-level care in their own homes, reduces the risk of hospital-acquired conditions such as delirium, especially in older adults. This commentary provides an overview of HAH, recent developments, and associated regulatory, safety, and quality issues.
Gibney BT, Roberts JM, D'Ortenzio RM, et al. RadioGraphics. 2021;41:2111-2126.
Hospitals are increasingly creating and updating their emergency disaster response plans. This guide assists hospital executives, quality & safety professionals, and risk managers by assessing potential hazards or failures in radiology departments in the event of disaster. Disaster planning tools, checklists, and other recommendations are described.  
Messing EG, Abraham RS, Quinn NJ, et al. Am J Nurs. 2022;122.
When hospitals began to fill up with COVID-19 patients, new strategies had to be developed and implemented quickly to reduce the spread of the virus. This article describes one strategy implemented by a New York hospital: relocating smart intravenous (iv) infusion pumps outside of patient rooms. Challenges, facilitators, and lessons learned are discussed.
Myren BJ, de Hullu JA, Bastiaans S, et al. Health Commun. 2022;37:191-201.
Understanding patient and provider preferences and perspectives is essential to effective error disclosure. This review explored the perspectives of patients and healthcare professionals involved in disclosure communication. Findings suggest that factors influencing effective disclosure occur on three levels: interpersonal skills (e.g., communication, adaptability, tailored communication, and creating space for emotions), organizational practices (e.g., prompt disclosure, private spaces, supporting patients to report errors), and supportive factors (e.g., disclosure training, culture of openness).

Ryan M, Mekel M, Sinha MS. UptoDate. November 30, 2021

Error disclosure is fundamental to addressing harm and psychological distress after medical error. This review highlights issues associated with surgical error disclosure. It summarizes literature covering legal and ethical issues, honest apology, and skill development to ensure apology communications are effective.
Bourne RS, Jennings JK, Panagioti M, et al. BMJ Qual Saf. 2022;Epub Jan 18.
Patients transferring from the intensive care unit (ICU) to the hospital ward may experience medication errors. This systematic review examined medication-related interventions on the impact of medication errors in ICU patients transferring to the hospital ward. Seventeen studies were included with five identified intervention components. Multi-component studies based on staff education and guidelines were effective at achieving almost four times more deprescribing on inappropriate medications by the time of discharge. Recommendations for improving transfers are included.
United States Meeting/Conference

Armstrong Institute for Patient Safety and Quality. June 1, 3 and 6, 2022, 9:00-11:00am each day.

Initiative appraisal is a necessary step toward shared learning and quality and safety program improvement. This virtual session will focus on the development of evaluation skills and strategies, with an emphasis on critique, design, and qualitative assessment.

Quick Safety. January 18, 2022(63):1-3.

Patients may not always reveal underlying causes of ill health such as alcohol and drug misuse or domestic violence due to embarrassment or shame. This newsletter piece shares recommendations for clinicians to explore the potential of an individual experiencing intimate partner violence to preserve their safety after a medical encounter.
Tools/Toolkit

RA-UK, the Faculty of Pain Medicine, RCoA Simulation and NHS Improvement

Standardization is a common strategy for preventing practice deviations that can contribute to harm. This tool outlines a three-step process for minimizing the occurrence of wrong-side peripheral nerve blocks that involves preparing for the procedure, stopping to perform a two-person site confirmation, and then administering the block.

This Month’s WebM&Ms

WebM&M Cases
Spotlight Case
John Landefeld, MD, MS, Sara Teasdale, MD, and Sharad Jain, MD |
A 65-year-old woman with a history of 50 pack-years of cigarette smoking presented to her primary care physician (PCP), concerned about lower left back pain; she was advised to apply ice and take ibuprofen. She returned to her PCP a few months later reporting persistent pain. A lumbar spine radiograph showed mild degenerative disc disease and the patient was prescribed hydrocodone/acetaminophen in addition to ibuprofen. In the following months, she was seen by video twice for progressive, more severe pain that limited her ability to walk. A year after the initial evaluation, the patient presented to the Emergency Department (ED) with severe pain. X-rays showed a 5 cm lesion in her lung, a small vertebral lesion and multiple lesions in her pelvic bones. A biopsy led to a diagnosis of lung cancer and magnetic resonance imaging (MRI) showed metastases to the liver and bone, as well as multiple small fractures of the pelvic girdle. Given the extent of metastatic disease, the patient decided against aggressive treatment with curative intent and enrolled in hospice; she died of metastatic lung cancer 6 weeks after her enrollment in hospice. The commentary summarizes the ‘red flag’ symptoms associated with low back pain that should prompt expedited evaluation, the importance of lung cancer screening for patients with a history of heavy smoking, and how pain-related stigma can contribute to contentious interactions between providers and patients that can limit effective treatment.
WebM&M Cases
Nandakishor Kapa, M.D., and José A. Morfín, M.D. |
A 69-year-old man with End-Stage Kidney Disease (ESKD) secondary to diabetes mellitus and hypertension, who had been on dialysis since 2014, underwent deceased donor kidney transplant. The case demonstrates the complex nature of management of allograft dysfunction due to vascular complications in a patient with deceased donor kidney transplant in the early post-transplant period. The commentary discusses how standardized follow-up imaging protocols can support early recognition and evaluation of allograft dysfunction due to vascular complications in kidney transplant recipients, as well the importance of team communication for patients requiring multiple interventions to reduce lag time in addressing further complications.
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.

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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