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March 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

Morisawa T, Saitoh M, Otsuka S, et al. J Clin Med. 2022;11:640.
Hospital-acquired functional decline can lead to poor health outcomes for frail older adults. This multicenter, prospective cohort study set in Japan assessed the effect of hospital-acquired function decline on post-discharge outcomes among older adults who had undergone cardiac surgery. The study observed poor prognostic outcomes in one-third of patients. Hospital-acquired functional decline was an independent predictor of poor prognosis. The authors encourage hospitals to develop and implement approaches to preventing functional decline in older adults.
Shah F, Falconer EA, Cimiotti JP. Qual Manag Health Care. 2022;Epub Feb 15.
Root cause analysis (RCA) is a tool commonly used by organizations to analyze safety errors. This systematic review explored whether interventions implemented based on RCA recommendations were effective at preventing similar adverse events in Veterans Health Affairs (VA) settings. Of the ten retrospective studies included in the review, all reported improvements following RCA-recommended interventions implementation, but the studies used different methodologies to assess effectiveness. The authors suggest that future research emphasize quantitative patient-related outcome measures to demonstrate the impact and value of RCAs.
Sun LY, Jones PM, Wijeysundera DN, et al. JAMA Netw Open. 2022;5:e2148161.
Previous research identified a relationship between anesthesia handoffs and rates of major complications and mortality compared to patients who had the same anesthesiologist throughout their procedure. This retrospective cohort study including over 102,000 patients in Ontario, Canada, explored this relationship among patients undergoing cardiac surgery. Analyses revealed that anesthesia handovers were associated with poorer outcomes (i.e., higher 30-day and one-year mortality rates, longer hospitalizations and intensive care unit stays) compared with patients who had the same anesthesiologist throughout their procedure.
Gionfriddo MR, Duboski V, Middernacht A, et al. PLoS ONE. 2021;16:e0260882.
Medication reconciliation is a widely used strategy to reduce medication adverse events in acute care; however, its use in primary care is less studied. The aims of this study were to identify behaviors indicative of obtaining a best possible medication history, barriers to medication reconciliation, and what improvements could be made. Numerous inconsistencies related to  medication reconciliation were identified (i.e. standardization, knowledge, importance, and inadequate integration).
Adler JL, Gurley K, Rosen CL, et al. Am J Emerg Med. 2022;54:228-231.
Analyzing reported errors and adverse events can help identify areas of concern needing improvement. Errors and/or adverse events occurring in one emergency department (ED) were classified into one of three groups (attributed to residents only, attendings only, or both), and into five further categories of event types (systems, documentation, diagnostic, procedural, and treatment).  Most errors were attributed to both residents and attendings, and treatment errors were the most common error type.
Sun LY, Jones PM, Wijeysundera DN, et al. JAMA Netw Open. 2022;5:e2148161.
Previous research identified a relationship between anesthesia handoffs and rates of major complications and mortality compared to patients who had the same anesthesiologist throughout their procedure. This retrospective cohort study including over 102,000 patients in Ontario, Canada, explored this relationship among patients undergoing cardiac surgery. Analyses revealed that anesthesia handovers were associated with poorer outcomes (i.e., higher 30-day and one-year mortality rates, longer hospitalizations and intensive care unit stays) compared with patients who had the same anesthesiologist throughout their procedure.
Ren DM, Abrams A, Banigan M, et al. Simul Healthc. 2022;17:e45-e50.
Effective team communication is a cornerstone to ensuring safe patient care, particularly during stressful situations. To evaluate baseline team communication behavior, clinicians at this institution participated in interprofessional video-recorded simulations of a code response and debriefing, followed by standardized evaluations by external reviewers. Evaluations indicate variable performance on different team communication behaviors (highest for escalating care and thinking out loud, lowest for verbally establishing leadership). The authors suggest that assessing baseline communication behaviors can guide future interventions to promote and improve quality and patient safety.
Bardach NS, Stotts JR, Fiore DM, et al. J Hosp Med. 2022;Epub Feb 4.
Patients and families represent an often untapped resource in identifying errors and adverse events. Using a mobile health tool, pediatric patients and families were encouraged to report safety events that occurred during the child’s hospital stay. These reports were compared with incident reports (IRs) submitted to the internal incident reporting system. Of the 51 potential IR observations, only one had been submitted to the IR system. Notably, differences in the number of reported events varied by race, ethnicity, insurance status, and other marginalized groups, highlighting a need to explicitly engage these populations. 
Morisawa T, Saitoh M, Otsuka S, et al. J Clin Med. 2022;11:640.
Hospital-acquired functional decline can lead to poor health outcomes for frail older adults. This multicenter, prospective cohort study set in Japan assessed the effect of hospital-acquired function decline on post-discharge outcomes among older adults who had undergone cardiac surgery. The study observed poor prognostic outcomes in one-third of patients. Hospital-acquired functional decline was an independent predictor of poor prognosis. The authors encourage hospitals to develop and implement approaches to preventing functional decline in older adults.
Hasselblad M, Morrison J, Kleinpell R, et al. BMJ Open Qual. 2022;11:e001315.
Disruptive patient behaviors in the hospital not only pose a risk to staff safety, but may also experience patient safety risks such as misdiagnosis. A behavioral intervention team (BIT) was deployed on two adult medical-surgical wards to evaluate the effectiveness of an intensive behavioral management intervention. While there were no differences in the number of behavioral issues reported in the intervention or control group, nurses rated BIT as the most beneficial support to manage patients exhibiting disruptive behaviors.
Lamoureux C, Hanna TN, Sprecher D, et al. Emerg Radiol. 2021;28:1135-1141.
Teleradiology - general radiologists who support several hospitals and read films remotely – can increase off-hours coverage but this approach can result in increased errors. This retrospective review examined errors and discrepancies between teleradiology findings and image interpretation from local facility radiologists. Most errors involved CT scans; the most common errors included missed fractures or dislocations and bleeding.
van der Nat DJ, Taks M, Huiskes VJB, et al. Int J Clin Pharm. 2022;44:539-547.
Medication reconciliation is a common tool used to identify medication discrepancies and inconsistencies. This study explored clinically relevant deviations in a patient’s medication list by comparing the personal heath record (used by patients) and medication reconciliation during hospital admission. Clinically relevant deviations were higher among patients with individual multi-dose packaging and patients using eight or more medications.
Cook-Richardson S, Addo A, Kim P, et al. J Surg Res. 2022;274:136-144.
Studies have shown that physicians are less likely to report errors and adverse events when compared to other clinicians. To increase the number of self-reports by surgeons, this hospital implemented a program of financial incentives. The incentive program led to an increase in reporting by physicians and physician assistants.
Ramsey L, Albutt AK, Perfetto K, et al. Int J Equity Health. 2022;21:13.
Patients with learning disabilities encounter unique patient safety threats. This qualitative study explored the care experiences and safety concerns of people with learning disabilities and their caregivers. Researchers identified several protective factors to avoid safety inequities and support safe, high-quality care, including access to social support and advocacy, appropriate staffing, sufficient expertise in care settings, care continuity, and accommodations of individualized care and communication needs.
Singh H, Connor DM, Dhaliwal G. BMJ. 2022;376:e068044.
System and clinician behaviors affect the reliability of the diagnostic process. This article shares five strategies to enhance individual clinician diagnostic practices which include seeking feedback, building learning into daily work, considering bias, enabling critical thinking, and teaming.
Shenoy A, Shenoy GN, Shenoy GG. Patient Saf Surg. 2022;16:10.
Defensive medicine refers to clinician behaviors with the intent to avoid malpractice risk due to care omissions. This article provides an overview of defensive medicine and its relationship to the taxonomies of medical errors and the risks that defensive medicine places on patients, hospital administrators, and systems, as well as clinicians.
Klein DO, Rennenberg RJMW, Koopmans RP, et al. J Patient Saf. 2021;17:e1234-e1240.
The Harvard Medical Practice Study (HMPS) and the Institute for Healthcare Improvement Global Trigger Tool (GTT) are two of the most widely used trigger tools to identify adverse events and prompt medical record review. Fifty studies using either trigger tool to prompt a medical record review (MRR) for potentially preventable adverse events were included in this literature review. MRR reveals more adverse events than other methods; however, research is still lacking or is of moderate quality. 
Shah F, Falconer EA, Cimiotti JP. Qual Manag Health Care. 2022;Epub Feb 15.
Root cause analysis (RCA) is a tool commonly used by organizations to analyze safety errors. This systematic review explored whether interventions implemented based on RCA recommendations were effective at preventing similar adverse events in Veterans Health Affairs (VA) settings. Of the ten retrospective studies included in the review, all reported improvements following RCA-recommended interventions implementation, but the studies used different methodologies to assess effectiveness. The authors suggest that future research emphasize quantitative patient-related outcome measures to demonstrate the impact and value of RCAs.
Buljac-Samardzic M, Dekker-van Doorn CM, Maynard MT. J Patient Saf. 2022;17:e929-e958.
Crew resource management (CRM), originally developed in aviation, has become popular in healthcare as a method to train groups to function as teams, rather than as a collection of individuals. This review identified ambiguities in CRM definition, outcome, and information, and highlighted the need for future research to expand beyond acute care and to investigate the sustainability of lessons learned from CRM trainings.
No results.

Quick Safety. February 14, 2022;(64):1-3.

Complete, appropriate reprocessing and sterilization of reusable medical instruments and devices is vital for infection prevention. This newsletter article shares actions to improve infection prevention, including standardized examination processes, infection preventionist involvement, and training focused on the safety impacts of incomplete processing and inappropriate reuse of single use items.

Bethesda, MD: National Institute of Neurological Disorders and Stroke. February 10, 2022. Publication No. NOT-NS-22-071.

Approaching diagnosis as a team activity is seen as a key approach to diagnostic effectiveness. This notice highlights the pending funding opportunity to launch Diagnostic Centers of Excellence to improve diagnosis of undiagnosed and unknown disease and research to inform improvement. In addition, a pending data coordination and management call for proposals to support the centers has been released.

Levy R, Vestal AJ. Politico. February 19, 2022.

Transmission of COVID-19 in the health care setting continues to be a concern. This article discusses an analysis of US government statistics tracking hospital-acquired COVID-19 infections and reasons that control efforts may be lagging, which include visitor masking choices and health care worker return to work post-COVID-19 behaviors.

Boodman SG. Washington Post. February 12, 2022.

Misdiagnosis over a long period of time can be acerbated by stigma and cognitive bias. This news story illustrates the problem of omissions due to potential stigma associated with patient mental health issues that contributed to a missed diagnosis. The author discusses how clinician experience led to flagging of a different testing approach to reveal a diagnosis that, once addressed, improved the patient's health.

Perry AF, Federico F, Huebner J. Boston, MA: Institute for Healthcare Improvement; 2021. 

The emergence of telemedicine during the COVID-19 pandemic has situated it to become an accepted model for health service provision despite safety concerns. This white paper discusses a 6-item framework to enhance the safety, equity, and person-centeredness of telemedicine and recommendations for embedding safer methods into telemedicine practice.

This Month’s WebM&Ms

WebM&M Cases
Spotlight Case
Katrina Pasao, MD and Pouria Kashkouli, MD, MS |
This Spotlight Case describes an older man incidentally diagnosed with prostate cancer, with metastases to the bone. He was seen in clinic one month after that discharge, without family present, and scheduled for outpatient biopsy. He showed up to the biopsy without adequate preparation and so it was rescheduled. He did not show up to the following four oncology appointments. Over the course of the following year, the patient’s son and daughter were contacted at various points to re-establish care, but he continued to miss scheduled appointments and treatments. During a hospital admission, a palliative care team determined that the patient did not have capacity to make complex medical decisions. He was discharged to a skilled nursing facility, and then to a board and care when he failed to improve. He missed two more oncology appointments before being admitted with cancer-related pain. Based on the patient’s poor functional status, he was not considered a candidate for additional therapy. After a discussion of goals of care with the patient and daughter, he was enrolled in hospice. The commentary outlines key elements for assessing patient capacity, the importance of understanding the patient’s psychosocial history, and strategies to strengthen psychosocial training for medical and nursing trainees.
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.

This Month’s Perspectives

Annual Perspective
A psychologically safe environment for healthcare teams is desirable for optimal team performance, team member well-being, and favorable patient safety outcomes. This piece explores facilitators of and barriers to psychological safety across healthcare settings. Future research directions examining psychological safety in healthcare are discussed.
Annual Perspective
Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.
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