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April 6, 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

Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2022. AHRQ Publication No. 22-0017.

The AHRQ Medical Office Survey on Patient Safety Culture  is designed to assess safety culture in outpatient clinics. The 2022 comparative data report includes data from 1,100 US medical offices and over 13,000 providers and staff. The highest-scoring composite measures are patient care tracking/follow-up and teamwork. Like the 2020 report, the lowest-scoring measure was work pressure and pace.
Humphrey KE, Sundberg M, Milliren CE, et al. J Patient Saf. 2022;18:130-137.
Poor provider-provider and provider-patient communication can result in significant morbidity and mortality to patients and play a role in malpractice claims. 498 closed malpractice claims were reviewed, with communication failures identified in nearly half. Of the communication errors that involved a failed handoff (47%), the majority could have potentially been prevented with a structured handoff tool. 
Lam D, Dominguez F, Leonard J, et al. BMJ Qual Saf. 2022;Epub Mar 22.
Trigger tools and incident reporting systems are two commonly used methods for detecting adverse events.  This retrospective study compared the performance of an electronic trigger tool plus manual screening versus existing incident reporting systems for identifying probable diagnostic errors among children with unplanned admissions following a prior emergency department (ED) visit. Of the diagnostic errors identified by the trigger tool and substantiated by manual review, less than 10% were identified through existing incident reporting systems.
Patterson ME, Bollinger S, Coleman C, et al. Res Social Adm Pharm. 2022;18:2830-2836.
Medication errors are common among older adults discharged to long-term care facilities. Researchers reviewed medication discrepancy data from four long-term care facilities over a 9-month period and found that nearly 41% of newly admitted or re-admitted residents had at least one medication discrepancy discovered at nursing home intake. Residents who were prescribed 14 or more medications and those with certain comorbidities (e.g., heart failure, anemia, hypertension) were at greatest risk for discrepancies. Higher discrepancies occurred with respiratory and analgesic medications, underscoring the importance of medication reconciliation for residents with respiratory conditions or pain.
Humphrey KE, Sundberg M, Milliren CE, et al. J Patient Saf. 2022;18:130-137.
Poor provider-provider and provider-patient communication can result in significant morbidity and mortality to patients and play a role in malpractice claims. 498 closed malpractice claims were reviewed, with communication failures identified in nearly half. Of the communication errors that involved a failed handoff (47%), the majority could have potentially been prevented with a structured handoff tool. 
Gonzalez-Smith J, Shen H, Singletary E, et al. NEJM Catalyst. 2022;3.
Clinical decision support (CDS) helps clinicians select appropriate medications, arrive at a correct diagnosis, and improve intraoperative decision making. Through interviews with health system executives, clinicians, and artificial intelligence (AI) experts, this study presents multiple perspectives on selection and adoption of AI-CDS in healthcare. Four emerging trends are presented: (1) AI must solve a priority problem; (2) the tool must be tested with the health system’s patient population; (3) it should generate a positive return on investment; and (4) it should be implemented efficiently and effectively.
Reese T, Wright A, Liu S, et al. Am J Health Syst Pharm. 2022;Epub Feb 10.
Computerized decision support alerts for drug-drug interactions are commonly overridden by clinicians. This study examined fifteen well-known drug-drug interactions and identified risk factors that could reduce risk in the majority of interactions (e.g., medication order timing, medication dose, and patient factors).
Cantor N, Durr KM, McNeill K, et al. J Intensive Care Med. 2022;Epub Mar 3.
Adverse events (AE) may lead to poor patient outcomes as well as increased financial costs. An analysis of more than 17,000 adult intensive care unit patients showed approximately 35% experienced at least one healthcare associated adverse event. Those patients had significantly longer hospital stays, experienced higher rates of in-hospital mortality, and required more invasive intensive care unit (ICU) interventions. Additionally, the total cost of the hospital stay was significantly higher, mostly due to increased length of stay.

Moore QT, Walker DA, Frush DP, et al. Radiol Technol. 2022;93(3):255-267. 

Improving patient safety related to radiation delivery is an ongoing priority. This study explores the interpersonal and institutional factors which influence the overall perception of radiation safety culture among U.S. radiologic technologists.
Gilmartin HM, Hess E, Mueller C, et al. Health Serv Res. 2022;57:385-391.
Ideal clinical learning environments (CLE) support employee engagement, satisfaction, and a culture of safety. The Learning Environment and High Reliability Practices Survey (LEHR) was used to determine the association between ideal CLE and job satisfaction, burnout, intent to leave, and staff turnover. Learning environments with higher average LEHR scores were associated with higher employee engagement, retention, and safety climate scores.
Patterson ME, Bollinger S, Coleman C, et al. Res Social Adm Pharm. 2022;18:2830-2836.
Medication errors are common among older adults discharged to long-term care facilities. Researchers reviewed medication discrepancy data from four long-term care facilities over a 9-month period and found that nearly 41% of newly admitted or re-admitted residents had at least one medication discrepancy discovered at nursing home intake. Residents who were prescribed 14 or more medications and those with certain comorbidities (e.g., heart failure, anemia, hypertension) were at greatest risk for discrepancies. Higher discrepancies occurred with respiratory and analgesic medications, underscoring the importance of medication reconciliation for residents with respiratory conditions or pain.
Rhodus EK, Lancaster EA, Hunter EG, et al. J Patient Saf. 2022;18:e503-e507.
Patient falls represent a significant cause of patient harm. This study explored the causes of falls resulting in harm among patients with dementia receiving or referred to occupational therapy (OT). Eighty root cause analyses (RCAs) were included in the analysis. Of these events, three-quarters resulted in hip fracture and 20% led to death. The authors conclude that earlier OT evaluation may decrease the frequency of falls among older adults with dementia.
Dieckmann P, Tulloch S, Dalgaard AE, et al. BMC Health Serv Res. 2022;22:307.
When staff feel psychologically safe, they are more likely to speak up about safety concerns. This study sought to explore the link between psychological safety and improvement work, and whether an existing model captures all the relevant ‘antecedents’ and ‘consequences’ of psychological safety.
Wilson C, Howell A-M, Janes G, et al. BMC Health Serv Res. 2022;22:296.
Feedback is an essential component of performance improvement and patient safety. Researchers conducted semi-structured interviews with emergency medical services (EMS) professionals in the United Kingdom about their perspectives on how feedback impacts patient care and safety. Findings highlight strong desire for feedback and concerns that inadequate feedback could inhibit learning from mistakes, limit professional development, and negatively impact patient safety.
Lam D, Dominguez F, Leonard J, et al. BMJ Qual Saf. 2022;Epub Mar 22.
Trigger tools and incident reporting systems are two commonly used methods for detecting adverse events.  This retrospective study compared the performance of an electronic trigger tool plus manual screening versus existing incident reporting systems for identifying probable diagnostic errors among children with unplanned admissions following a prior emergency department (ED) visit. Of the diagnostic errors identified by the trigger tool and substantiated by manual review, less than 10% were identified through existing incident reporting systems.

Lane S, Gross M, Arzola C, et al. Can J Anaesth. Epub 2022 Mar 22.

Intraoperative anesthesia handovers can increase patient safety risks. Based on video-recorded handovers and anesthetic records, researchers at this tertiary care center found that introduction of an intraoperative handover checklist improved handover completeness, which may decrease risk for adverse events.
Furlan L, Francesco PD, Costantino G, et al. J Intern Med. 2022;291:397-407.
Overtreatment and overuse can have unanticipated consequences, ranging from patient anxiety while awaiting test results to medical complications. The authors identify several factors that can contribute to patient overtreatment (fear of uncertainty, cognitive bias, applying low-quality evidence, and overfocusing on diagnosis). Interventions to overcome these issues include educating clinicians that uncertainty is a part of medicine and shifting to a focus on patient-centered management rather than focusing on identifying a diagnosis.
Schattner A. J Gen Intern Med. 2022;37:664-667.
Interest in harm resulting from medical care and patient safety has evolved over several decades. This commentary discusses changes in medical harm over time and shares five areas of focus to drive improvement: time constraints, increased care options, information technology, knowledge complexity, and patient change.
Brierley-Jones L, Ramsey L, Canvin K, et al. Res Involv Engagem. 2022;8:8.
Patient engagement in safety efforts is encouraged, but patients are less often included as active participants in designing patient safety interventions. This review identified 52 studies that included mental health patients in the design, delivery, implementation, and/or evaluation of patient safety research. The authors argue that increased inclusion of patients in safety research may lead to development of higher quality safety interventions.

Collaborative for Accountability and ImprovementApril 26, 2022.

Communication and resolution programs (CRP) can improve response to patients and families after a harmful medical error. This session examined how silos negatively impact transparency after error and how CRPs can reduce siloed communication. The session features Dr. Jo Shapiro as a panelist.
Multi-use Website

National Center for Chronic Disease Prevention and Health Promotion, Division of Reproductive Health; Centers for Disease Control and Prevention. 

Maternal harm during and after pregnancy is a sentinel event. This campaign encourages women, families, and health providers to identify and speak up with concerns about maternal care and act on them. The program seeks to inform the design of support systems and tool development that enhance maternal safety.

Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2022. AHRQ Publication No. 22-0017.

The AHRQ Medical Office Survey on Patient Safety Culture  is designed to assess safety culture in outpatient clinics. The 2022 comparative data report includes data from 1,100 US medical offices and over 13,000 providers and staff. The highest-scoring composite measures are patient care tracking/follow-up and teamwork. Like the 2020 report, the lowest-scoring measure was work pressure and pace.

Fiore K. MedPage Today. March 28, 2022.

Experts are concerned that convictions for medical error have the potential to limit dialogue on the front line about medical mistakes. This article summarizes discussions regarding the verdict to convict a nurse due to a workaround that resulted in a medication error and patient death.

This Month’s WebM&Ms

WebM&M Cases
Robert Scott Kriss, DO |
This WebM&M describes an adverse event due to mislabeling or “syringe swap” in a preoperative patient. The commentary outlines several recommendations and safeguards to ensure that medications administration is safe.
WebM&M Cases
Spotlight Case
David Barnes, MD and Joseph Yoon, MD |
An 18-month-old girl presented to the Emergency Department (ED) after being attacked by a dog and sustaining multiple penetrating injuries to her head and neck. After multiple unsuccessful attempts to establish intravenous access, an intraosseous (IO) line was placed in the patient’s proximal left tibia to facilitate administration of fluids, blood products, vasopressors, and antibiotics.  In the operating room, peripheral intravenous (IV) access was eventually obtained after which intraoperative use of the IO line was restricted to a low-rate fluid infusion.  An hour into the operation, the anesthesiologist found her left calf to be warm and tense, presumably due to fluid extravasation from the IO line.  The IO line was removed, and the Orthopedic Surgery service was consulted intraoperatively due to concern for acute compartment syndrome.  Signs of compartment syndrome eventually resolved without any surgical intervention.  The commentary summarizes complications associated with IO lines, the importance of anticipating procedural complications, and methods to identify the signs and symptoms of acute compartment syndrome.
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.

This Month’s Perspectives

Perspective
This piece discusses the role that media plays in affecting patient safety.
Interview
Michael L. Millenson is the President of Health Quality Advisors LLC, author of the critically acclaimed book Demanding Medical Excellence: Doctors and Accountability in the Information Age, and an adjunct associate professor of medicine at Northwestern University’s Feinberg School of Medicine. He serves on the Board of Directors for Project Patient Care, and earlier in his career he was a healthcare reporter for the Chicago Tribune, where he was nominated three times for a Pulitzer Prize. We spoke with him about how patient safety efforts are shaped by the media and how the role of media has changed since our original discussion on the role of media in patient safety (published in October of 2009 (https://psnet.ahrq.gov/perspective/conversation-charles-ornstein; https://psnet.ahrq.gov/perspective/media-essential-if-sometimes-arbitrary-promoter-patient-safety)).
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