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February 9, 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

Dionisi S, Di Simone E, Liquori G, et al. Public Health Nurs. 2021;Epub Dec 31.
Causes of medication errors occurring in home care may differ from those in the hospital setting. This systematic review identified three main risk factors for medication errors in the home: transition documentation, medication reconciliation, and communication among the multidisciplinary team. Most studies recommend involvement of a pharmacist as a member of the care team.
Sawicki JG, Nystrom DT, Purtell R, et al. Hosp Pract (1995). 2021;49:437-444.
Diagnostic errors are a significant patient safety issue. This systematic review describes the scope of existing research regarding diagnostic errors in pediatric patients. The authors concluded that there are limited data describing diagnostic errors in pediatric hospital settings. Findings suggest that the prevalence of diagnostic error in pediatric hospitals varied and largely depended on the measurement technique and hospital setting.
Khoong EC, Sharma AE, Gupta K, et al. J Gen Intern Med. 2022;37:1270-1274.
In response to concerns about COVID-19 transmission, many ambulatory care visits have transitioned to telehealth visits. This commentary describes the impact of telehealth on diagnostic errors and medication safety in ambulatory settings. Recommendations to further understand the impact of telemedicine on patient safety include: systematically measuring patient safety outcomes and increasing reporting of safety incidents; identifying the patients and clinical scenarios with the greatest risk of unsafe telehealth care; identifying and supporting best practices to ensure equal access to safe telehealth.
Herchline D, Rojas C, Shah AA, et al. Pediatr Qual Saf. 2022;7:e519.
Prior research has shown low rates of voluntary safety event reporting by resident physicians. This hospital implemented a quality improvement (QI) project to increase reporting by pediatric residents. The QI team identified barriers to reporting (e.g., lack of awareness of the organization’s event reporting system, safety culture) and then implemented a multifactorial intervention to increase reporting. The number of reports submitted increased, as did the number of unique residents submitting reports.
Murata M, Nakagawa N, Kawasaki T, et al. Am J Emerg Med. 2022;52:13-19.
Transporting critically ill patients within a hospital (e.g., to radiology for diagnostic procedures) is necessary but also poses safety threats. The authors conducted a systematic review and meta-analysis of all types of adverse events, critical or life-threatening adverse events, and death occurring during intra-hospital transport. Results indicate that adverse events can occur in intra-hospital transport, and that frequency of critical adverse events and death are low.
Schiff GD, Volodarskaya M, Ruan E, et al. JAMA Netw Open. 2022;5:e2144531.
Improving diagnosis is a patient safety priority. Using data from patient safety incident reports, malpractice claims, morbidity and mortality reports, and focus group responses, this study sought to identify “diagnostic pitfalls,” defined as clinical situations vulnerable to errors which may lead to diagnostic errors. The authors identified 21 generic diagnostic pitfall categories involving six different aspects of the clinical interaction – diagnosis and assessment, history and physical, testing, communication, follow-up, and other pitfalls (e.g., problems with inappropriate referral, urgency of the clinical situation not appreciated). The authors suggest that these findings can inform education and quality improvement efforts to anticipate and prevent future errors.
Ziedan E, Kaestner R. Eval Rev. 2021;45:359-411.
The Centers of Medicare & Medicaid Service (CMS) Hospital Readmissions and Reduction Program (HRRP) financially penalizes hospitals if patients with certain medical conditions are readmitted. This study analyzed the empirical approaches used in prior research to evaluate the effectiveness of the HRRP. The authors conclude that approaches used in some prior research lacked internal validity and may not indicate causal consequences of the program on readmissions.
Siewert B, Swedeen S, Brook OR, et al. Radiology. 2022;302:613-619.
Adverse events can contribute to physical, financial, or emotional harm. Based on radiology-related events identified in a hospital incident reporting system, the authors identified the types of incidents contributing to emotional harm in patients – failure to be patient-centered, disrespectful communication, privacy violations, minimization of patient concerns, and loss of property. The authors also proposed several improvement strategies, including communication training and improvement of communication processes, individual feedback, and improvements to existing processes and systems.
Emond YEJJM, Calsbeek H, Peters YAS, et al. Br J Anaesth. 2022;128:562-573.
A necessary part of successful implementation of new guidelines is ensuring continued adherence. Nine Dutch hospitals implemented a multifaceted program (IMPlementatie Richtlijnen Operatieve VEiligheid [IMPROVE]) to support application of surgical guidelines. Results of guideline use were mixed.
Organizational Policy/Guidelines
Thibault R, Abbasoglu O, Ioannou E, et al. Clin Nutr. 2021;40:5684-5709.
Mistakes in hospital dietary services can contribute to allergic reactions and patient malnourishment. This guidance shares an improvement approach to care environment food provision that considers clinical concerns and patient limitations as steps toward enhancing patient care.
Khoong EC, Sharma AE, Gupta K, et al. J Gen Intern Med. 2022;37:1270-1274.
In response to concerns about COVID-19 transmission, many ambulatory care visits have transitioned to telehealth visits. This commentary describes the impact of telehealth on diagnostic errors and medication safety in ambulatory settings. Recommendations to further understand the impact of telemedicine on patient safety include: systematically measuring patient safety outcomes and increasing reporting of safety incidents; identifying the patients and clinical scenarios with the greatest risk of unsafe telehealth care; identifying and supporting best practices to ensure equal access to safe telehealth.
Steffany M. J Healthc Risk Manag. 2022;41:31-38.
Concerns have been raised regarding the need to assess the competencies of aging physicians. This article discusses how different entities (e.g., health systems, states, and professional medical organizations) are addressing this issue through competency-based assessments, peer review, and credentialing requirements.
Lazzara EH, Salisbury M, Hughes AM, et al. J Patient Saf. 2022;18:e275-e281.
Morbidity and mortality conferences (MMC) serve as a way for health care teams to discuss adverse events and errors with the goal of improving patient safety. This article presents five recommendations to improve MMC: encourage culture change; allocate ample time for open communication to foster innovative thinking; take a global approach; learn from errors and near misses; and do not just talk the talk, but also walk the walk.
Vogus TJ, Wilson AD, Randall KH, et al. BMJ Qual Saf. 2022;31:230-233.
Achieving high-reliability remains a goal for hospitals and care teams. The authors of this commentary discuss how the COVID-19 pandemic impacted high-reliability practices and suggest a more inclusive approach to creating and sustaining high reliability by involving patients, families, and other types of care professionals (such as chaplains, social workers).
AMA J Ethics. 2022;23:E931-936.
Disrespectful behavior detracts from the work culture needed to provide safe care. This commentary discusses a case involving disrespectful behavior toward a surgical resident that resulted in lack of the raising of a concern. The piece examines the role teams play in enabling poor behavior and their responsibility to address each situation as a component of a safety culture.
Borycki EM, Kushniruk AW. Stud Health Technol Inform. 2022;289:447-451.
Although health information technology has improved many aspects of patient care, unintended negative consequences may also occur. This review aimed to develop a maturity model specific to technology-induced errors and improve safety across the organization. Five maturity levels, from ad hoc to formalized, are described.
Sawicki JG, Nystrom DT, Purtell R, et al. Hosp Pract (1995). 2021;49:437-444.
Diagnostic errors are a significant patient safety issue. This systematic review describes the scope of existing research regarding diagnostic errors in pediatric patients. The authors concluded that there are limited data describing diagnostic errors in pediatric hospital settings. Findings suggest that the prevalence of diagnostic error in pediatric hospitals varied and largely depended on the measurement technique and hospital setting.
Procaccini D, Kim JM, Lobner K, et al. Jt Comm J Qual Patient Saf. 2022;48:154-164.
Weight-based medication dosing is a common source of medication errors in children. This systematic review identified limited evidence that overweight and obese children maybe be at increased risk of weight-based medication dosing errors, but the authors note that the clinical significance is unknown.
Dionisi S, Di Simone E, Liquori G, et al. Public Health Nurs. 2021;Epub Dec 31.
Causes of medication errors occurring in home care may differ from those in the hospital setting. This systematic review identified three main risk factors for medication errors in the home: transition documentation, medication reconciliation, and communication among the multidisciplinary team. Most studies recommend involvement of a pharmacist as a member of the care team.
No results.

Silver Springs, MD: US Food and Drug Administration: June 25, 2021.

Incomplete reprocessing of reusable flexible endoscopes can result in nosocomial infection. This announcement highlights recent guidance to improve the safe reuse of bronchoscopes with a focus on scope design, sterile processing, and infection control program management.

Medication Safety Alert! Acute care edition. January 27, 2022;27(2):1-6.

Medication errors are a consistent threat to safe patient care. This newsletter article analyzes events submitted to the Institute for Safe Medication Practices in 2021 and highlights those that are COVID-related or common, yet preventable, if practice recommendations and system improvements are applied.

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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