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May 4, 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

Davidson C, Denning S, Thorp K, et al. BMJ Qual Saf. 2022;Epub Apri 15.
People of color experience disproportionately higher rates of maternal morbidity and mortality. As part of a larger quality improvement and patient safety initiative to reduce severe maternal morbidity from hemorrhage (SMM-H), this hospital analyzed administrative data stratified by race and ethnicity, and noted a disparity between White and Black patients. Review of this data was integrated with the overall improvement bundle. Post-implementation results show that SMM-H rates for Black patients decreased.
Mariyaselvam MZA, Patel V, Young HE, et al. J Patient Saf. 2022;18:e387-e392.
A retained foreign object can lead to serious clinical consequences and is considered a never event. Researchers analyzed a national patient safety incident database to identify factors contributing to guidewire retention and potential preventative measures. Findings indicate that most retained guidewires are identified after the procedure. The authors suggest that system changes or design modifications to central venous catheter equipment is one approach to prevent guidewire attention.
Meyer AND, Scott TMT, Singh H. JAMA Netw Open. 2022;5:e228568.
Delayed communication of abnormal test results can contribute to diagnostic and treatment delays, patient harm, and malpractice claims. The Department of Veterans Affairs specifies abnormal test results be communicated to the patient within seven days if treatment is required, and within 14 days if no treatment is required. In the first full year of the program, 71% of abnormal test results and 80% of normal test results were communicated to the patient within the specified timeframes. Performance varied by facility and type of test.
Enumah SJ, Resnick AS, Chang DC. PLOS ONE. 2022;17:e0266696.
While quality and patient safety initiatives are implemented to improve patient outcomes, they also typically include a financial cost which must be balanced with expected outcomes. This study compared hospitals’ financial performance (i.e., financial margin and risk of financial distress) and outcomes (i.e., 30-day readmission rates, patient safety indicator-90 (PSI-90)) using data from the American Hospital Association and Hospital Compare. Hospitals in the best quintiles of readmission rates and PSI-90 scores had higher operating margins compared to the lowest rated hospitals.
Mariyaselvam MZA, Patel V, Young HE, et al. J Patient Saf. 2022;18:e387-e392.
A retained foreign object can lead to serious clinical consequences and is considered a never event. Researchers analyzed a national patient safety incident database to identify factors contributing to guidewire retention and potential preventative measures. Findings indicate that most retained guidewires are identified after the procedure. The authors suggest that system changes or design modifications to central venous catheter equipment is one approach to prevent guidewire attention.
Colombini N, Abbes M, Cherpin A, et al. Int J Med Inform. 2022;160:104703.
Computerized provider order entry (CPOE) refers to a system in which clinicians directly place orders electronically to be sent to the receiver (e.g., pharmacist). This French hospital analyzed hospital discharge orders (HDO) over a six-month period to evaluate the use rate of CPOE, prescription concordance between CPOE-edited HDO, exit prescriptions transcribed in the discharge summary, and prescribing error rate. Use of CPOE and pharmacist intervention reduced prescribing errors of hospital discharge orders.
Díez R, Cadenas R, Susperregui J, et al. Int J Environ Res Public Health. 2022;19:4313.
Older adults living in nursing homes are at increased risk of polypharmacy and its associated adverse outcomes, such as drug-drug interactions. The medication records of 222 older adult residents of one Spanish nursing home were screened for potential drug-drug adverse events. Nearly all included residents were taking at least one potentially inappropriate medication, and drug-drug interactions were common.
Schnock KO, Roulier S, Butler J, et al. J Patient Saf. 2022;18:e407-e413.
Patient safety dashboards are used to communicate real-time patient data to appropriately augment care. This study found that higher usage of an electronic patient safety dashboard resulted in lower 30-day readmission rates among patients discharged from adult medicine units compared to lower usage groups.
Davidson C, Denning S, Thorp K, et al. BMJ Qual Saf. 2022;Epub Apri 15.
People of color experience disproportionately higher rates of maternal morbidity and mortality. As part of a larger quality improvement and patient safety initiative to reduce severe maternal morbidity from hemorrhage (SMM-H), this hospital analyzed administrative data stratified by race and ethnicity, and noted a disparity between White and Black patients. Review of this data was integrated with the overall improvement bundle. Post-implementation results show that SMM-H rates for Black patients decreased.

Jagsi R, Griffith KA, Vicini F, et al for the Michigan Radiation Oncology Quality Consortium. JAMA OncolEpub 2022 Apr 21. 

Concordance of patient-reported symptoms and provider-documented symptoms is necessary for appropriate patient care and has clinical implications for research. This study compared patient-reported symptoms (pain, pruritus, edema, and fatigue) following radiotherapy for breast cancer with provider assessments. Underrecognition of at least one symptom occurred in more than 50% of patients. Underrecognition was more common in Black patients and those seen by male physicians. The authors suggest that interventions to improve communication between providers and patients may not only improve outcomes but also reduce racial disparities.
Kuske S, Willmeroth T, Schneider J, et al. BMJ Open Qual. 2022;11:e001741.
Comprehensive implementation of reporting and learning systems (RLS, also known as incident reporting systems) is important for its successful use as a patient safety improvement tool. This study aimed to develop a set of “implementation patient safety indicator(s) sets” to monitor the extent to which an RLS has been implemented in hospitals. Implementation outcomes include acceptability, adoption, appropriateness, implementation costs, feasibility, fidelity, penetration, and sustainability. Study participants rated acceptability and sustainability as most relevant to successful implementation.
Riblet NB, Gottlieb DJ, Watts BV, et al. J Nerv Ment Dis. 2022;210:227-230.
Unplanned discharges (also referred to as leaving against medical advice) can lead to adverse patient outcomes. This study compared unplanned discharges across Veterans Health Affairs (VHA) acute inpatient and residential mental health treatment settings over a ten-year period and found that unplanned discharges are significantly higher in mental health settings. The authors recommend that unplanned discharges be measured to assess patient safety in mental health.
Madden C, Lydon S, Murphy AW, et al. Fam Pract. 2022;Epub Apr 20.
Patient complaints and patient-reported incidents can help identify safety issues. This study compared clinician perceptions and patients’ accounts regarding patient safety incidents and identified a significant difference in perceptions about incident severity. Patients’ accounts of incidents commonly described deficiencies related to communication, staff performance, compassion, and respect.
Gilbert GL, Kerridge I. BMC Health Serv Res. 2022;22:504.
Hospital transmission of COVID-19 has necessitated review of organization infection prevention and control (IPC) policies and practices. This study, conducted before the pandemic, compared IPC attitudes and practices of nurses and physicians, and how these differences affect interpersonal relationships. Both professions described unflattering and stereotypical behaviors of the other (i.e., doctors are unaware or disdainful of IPC; “bossy” nurses).  Many IPC policies implemented during the pandemic, such as encouraging all healthcare workers to speak up about infection prevention breaches, were accepted by both professions, and the authors recommend seizing on this interprofessional unity to continue adherence to all IPC policies.
Wailling J, Kooijman A, Hughes J, et al. Health Expect. 2022;Epub Mar 23.
Harm resulting from patient safety incidents can be compounded if investigating responses ignore the human relationships involved. This article describes how compounded harm arises, and it recommends the use of a restorative practices. A restorative approach focuses on (1) who has been hurt and their needs, and who is responsible for addressing those needs, (2) how harms and relationships can be repaired, and avenues to prevent the incident from reoccurring.
Montgomery A, Lainidi O. Front Psychiatry. 2022;13:818393.
Difficulty speaking up about patient safety concerns and unprofessional behavior indicates a safety culture deficiency. This article discusses the relationship between silence, burnout, and quality of care, emphasizing how silence evolves during medical education and continues into clinical training, eventually impacting healthcare professional burnout, patient safety and quality of care.
No results.

The APSF Committee on Technology. APSF Newsletter2022;37(1):7–8.

Variation across standards and processes can result in misunderstandings that disrupt care safety. This guidance applied expert consensus to examine existing anesthesia monitoring standards worldwide. Recommendations are provided for organizations and providers to guide anesthesia practice in a variety of environments to address patient safety issues including accidental patient awareness during surgery.

Doty MM, Horstman C, Shah A et al. Issue Brief. New York, NY: Commonwealth Fund: April 2022.

Bias in any form degrades the safety and effectiveness of communication and care. This report summarizes data documenting the impact of racial and ethnic discrimination on older adult patients. It provides recommendations that include increasing content in medical school curriculum to raise awareness of biased medical care and tailoring communication needs to ethnic communities as steps toward reducing discrimination.

London UK: Patient Safety Learning: 2022.

Unsafe care affects a wide range of individuals and organizations physically, emotionally, and financially. This report examines large system failures in the UK National Health Service to suggest actions that support learning and improvement. The publication highlights how public investigations, government reports, legal actions, and patient complaints can provide information to support the systems approach required to arrive at safe care.

Arnetz JE. Jt Comm J Qual Patient Saf. 2022;48(4):241-245.

Patient violence toward health care workers is a common, yet underreported, influence on care safety. This commentary summarizes policies in place to address patient violence and highlights Joint Commission standards developed to reduce the potential for violence in care environments. Improved reporting, organizational engagement, and safety culture development are among the strategies recommended.

Silver Spring, MD: US Food and Drug Administration; April 5, 2022.

The challenge of medical device sterilization has shifted the design of some products with disposable elements in order to reduce opportunities for human error that increase infection potential during reuse. The publication supports the complete adoption of disposable duodenoscopes or scope components as a safety measure.

This Month’s WebM&Ms

WebM&M Cases
Garima Agrawal, MD, MPH, and Mithu Molla, MD, MBA |
This WebM&M describes two cases involving patients who became unresponsive in unconventional locations – inside of a computed tomography (CT) scanner and at an outpatient transplant clinic – and strategies to ensure that all healthcare teams are prepared to deliver advanced cardiac life support (ACLS), such as the use of mock codes and standardized ACLS algorithms. 
WebM&M Cases
Alexandria DePew, MSN, RN, James Rice, & Julie Chou, BSN |
This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.
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.

This Month’s Perspectives

Remle P. Crowe
Interview
Remle Crowe, PhD, NREMT, is the Director of Clinical and Operational Research at ESO. In her professional role, she provides strategic direction for the research mission of the organization, including oversight of a warehouse research data set of de-identified records (the ESO Data Collaborative). We spoke with her about how data is being used in the prehospital setting to improve patient safety.
Perspective
This piece focuses on measuring and monitoring patient safety in the prehospital setting.
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