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July 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

Akinyelure OP, Colvin CL, Sterling MR, et al. BMC Geriatr. 2022;22:476.
Frail older adults are at increased risk of adverse events including rehospitalization and overtreatment. In this study, researchers assessed the association of care coordination and preventable adverse events in frail older adults. Compared with non-frail older adults, frail older adults reported experiencing more adverse events they believed could have been prevented with better care coordination.
Lawson MB, Bissell MCS, Miglioretti DL, et al. JAMA Oncol. 2022;8:1115-1126.
Delays in breast cancer diagnosis and treatment can threaten patient safety. This study analyzed data from a large US breast cancer screening consortium to evaluate differences in diagnostic follow-up among racial and ethnic groups. Findings indicate that Black women were most likely to experience diagnostic delays (between receipt of abnormal screening result to biopsy) after adjusting for individual-, neighborhood-, and health care-level factor, emphasizing the need to address the potential for systemic racism in healthcare.
Howell EA, Sofaer S, Balbierz A, et al. Obstet Gynecol. 2022;139:1061-1069.
Health equity in maternal safety is a major patient safety goal. Researchers interviewed health care professionals, including frontline nurses and physicians, chief medical officers, and quality and safety officers, from high- and low-performing hospitals. Six themes emerged differentiating high and low performers: 1) senior leadership involved in day-to-day quality activities and dedicated to quality improvement, 2) a strong focus on standards and standardized care, 3) strong nurse-physician communication and teamwork, 4) adequate physician and nurse staffing and supervision, 5) sharing of performance data with nurses and other frontline clinicians, and 6) explicit awareness that racial and ethnic disparities exist and that racism and bias in the hospital can lead to differential treatment. PSNet offers a Patient Safety Primer and Curated Library on maternal safety.
Howell EA, Sofaer S, Balbierz A, et al. Obstet Gynecol. 2022;139:1061-1069.
Health equity in maternal safety is a major patient safety goal. Researchers interviewed health care professionals, including frontline nurses and physicians, chief medical officers, and quality and safety officers, from high- and low-performing hospitals. Six themes emerged differentiating high and low performers: 1) senior leadership involved in day-to-day quality activities and dedicated to quality improvement, 2) a strong focus on standards and standardized care, 3) strong nurse-physician communication and teamwork, 4) adequate physician and nurse staffing and supervision, 5) sharing of performance data with nurses and other frontline clinicians, and 6) explicit awareness that racial and ethnic disparities exist and that racism and bias in the hospital can lead to differential treatment. PSNet offers a Patient Safety Primer and Curated Library on maternal safety.
Liberman AL, Cheng NT, Friedman BW, et al. Diagnosis (Berl). 2022;9:225-235.
Missed diagnosis of stroke in emergency medicine settings is an important patient safety problem. In this study, researchers interviewed emergency medicine physicians about their perspectives on diagnostic neurology and use of clinical decision support (CDS) tools. Themes emerged related to challenges in diagnosis, neurological complaints, and challenges in diagnostic decision-making in emergency medicine, more generally. Participating physicians were enthusiastic about the possibility of involving CDS tools to improve diagnosis for non-specific neurological complaints.
Graham JMK, Ambroggio L, Leonard JE, et al. Diagnosis (Berl). 2022;9:216-224.
Timely and effective feedback regarding diagnostic errors can reduce future misdiagnosis and prevent overtreatment. Pediatric emergency clinicians were asked about their attitudes towards, and effectiveness of, three diagnostic feedback modalities. Case-based feedback from peers was rated as most likely to improve future practice and none of the modalities was rated as providing emotional support.
Oyegoke S, Gigli KH. J Patient Saf. 2022;18:e753-e759.
Strong safety culture is a crucial pillar of patient safety improvement efforts. Based on data from the Medical Office Survey on Patient Safety Culture, this study found that staff in pediatric primary care settings had generally positive perceptions about safety culture. Researchers identified differences in perceptions based on staff role, such as between administration/management staff and direct care staff.
Khan A, Baird JD, Kelly MM, et al. Pediatrics. 2022;149:e2021053913.
Patient and family engagement in safety efforts is supported in research but patients and clinicians still experience barriers in providing and accepting feedback. In this study, parents and caregivers of medically complex children reported uncertainty about whether and to whom to report concerns. Other themes included misalignment of staff and parent expectations of care and staff and leadership buy-in on the value of parent engagement.
Akinyelure OP, Colvin CL, Sterling MR, et al. BMC Geriatr. 2022;22:476.
Frail older adults are at increased risk of adverse events including rehospitalization and overtreatment. In this study, researchers assessed the association of care coordination and preventable adverse events in frail older adults. Compared with non-frail older adults, frail older adults reported experiencing more adverse events they believed could have been prevented with better care coordination.
Vallamkonda S, Ortega CA, Lo YC, et al. Stud Health Technol Inform. 2022;290:120-124.
Prior research has found that electronic health record (EHR) implementation has introduced risks to patient safety. Using data from one hospital’s EHR system, this study reviewed active allergy alerts in patient records and concluded that 37% of those records required reconciliation of allergy information across different areas of the EHR. These findings highlight the need for automated reconciliation algorithms and clinical decision support tools to help clinicians identify potential allergy discrepancies and avoid patient safety risks.
Lawson MB, Bissell MCS, Miglioretti DL, et al. JAMA Oncol. 2022;8:1115-1126.
Delays in breast cancer diagnosis and treatment can threaten patient safety. This study analyzed data from a large US breast cancer screening consortium to evaluate differences in diagnostic follow-up among racial and ethnic groups. Findings indicate that Black women were most likely to experience diagnostic delays (between receipt of abnormal screening result to biopsy) after adjusting for individual-, neighborhood-, and health care-level factor, emphasizing the need to address the potential for systemic racism in healthcare.
Kepner S, Jones RM. Patient Safety. 2022;4:18-33.
Acute care facilities in Pennsylvania are required to report all Incidents and Serious Events to the state’s Patient Safety Authority. This study updates the 2020 report. Similar to prior reports, Error Related to Procedure/Treatment/Test remained the most commonly reported events, followed by Medication Error, Complication of Procedure/Treatment/Test, and Fall.
Niederhauser A, Schwappach DLB. Health Sci Rep. 2022;5:e631.
Ensuring that healthcare staff feel comfortable speaking up about safety concerns is an important component of safety culture. This cross-sectional study explored speaking up behaviors and perceptions among healthcare workers in rehabilitation clinics in Switzerland. Barriers to speaking up included expectations of a lack of productive response to the safety concern, presence of patients, and concerns about reactions from involved individuals.
Brown A, Cavell G, Dogra N, et al. Int J Med Inform. 2022;164:104780.
Alert fatigue and subsequent overrides are known contributors to preventable adverse events particularly for high-risk drug-drug interactions. Researchers assessed prescribers’ actions following an alert for new prescriptions of Low Molecular Weight Heparins (LMWHs) to patients currently prescribed Direct Acting Anticoagulants (DOACs). More than half of the alerts were overridden but were appropriate and justified in most cases.
Donnelly LF, Uhlhorn E, Bargmann-Losche J, et al. J Patient Exp. 2022;9:237437352211026.
Combining patient complaints and staff incident reports allows hospitals to better understand causes of patient harm. This children’s hospital designed a program to investigate serious experience events (SEE) modeled after their serious safety events (SSE) program. Through case studies, the authors describe how patient complaints were investigated to improve both patient experience and safety.
Young RA, Fulda KG, Espinoza A, et al. J Am Board Fam Med. 2022;35:610-628.
Identifying barriers and facilitators of medication safety is a patient safety research priority. In this systematic review characterizing the research on medication safety in primary care, researchers found that the majority of studies focused on high-risk populations (such as older adults with polypharmacy) and measured potential harms (such as potentially inappropriate prescribing or potential prescribing omissions) rather than actual harms.
Alexander R, Waite S, Bruno MA, et al. Radiology. 2022:212631.
To reduce medical errors caused by fatigue, the Accreditation Council for Graduate Medical Education (ACGME) adopted duty hour restrictions for ACGME-accredited residency programs; however, other healthcare fields have not yet done so. This review presents the limited existing evidence for regulating duty hours for radiologists and proposes that additional research needs to be completed before implementing restrictions.
No results.

Institute for Safe Medication Practices.

A Just Culture supports effective reporting and learning from mistakes. This scholarship, inspired by the work and leadership of Judy Smetzer, former editor of the ISMP Medication Safety Alert! newsletter, will support three team or individual certifications in Just Culture practice. The application process is now closed.

Rockville, MD: Agency for Health Quality and Research; June 2022.

The potential for workplace violence degrades patient and staff safety. AHRQ is developing a survey item set that will help nursing homes identify and improve factors associated with workplace safety. The Workplace Safety Supplemental Item Set will assess the extent to which nursing homes’ organizational culture supports workplace safety. The new supplemental item set can be administered optionally at the end of the SOPS Nursing Home Survey. AHRQ will build this new measure of workplace safety upon its existing and highly successful SOPS program. This announcement calls for nursing homes to participate in a pilot study to test the application of the supplemental item set in the field.

This Month’s WebM&Ms

WebM&M Cases
Spotlight Case
Kevin J. Keenan, MD, and Daniel K. Nishijima, MD, MAS |
A 58-year-old man with a past medical history of seizures presented to the emergency department (ED) with acute onset of left gaze deviation, expressive aphasia, and right-sided hemiparesis. The patient was evaluated by the general neurology team in the ED, who suspected an acute ischemic stroke and requested an evaluation by the stroke neurology team but did not activate a stroke alert. The stroke team concluded that the patient had suffered a focal seizure prior to arrival and had postictal deficits. The stroke team did not order emergent CT angiography and perfusion imaging but recommended routine magnetic resonance imaging with angiography (MRI/MRA) for further evaluation, which showed extensive cerebral infarction in the distribution of an occluded left middle cerebral artery (MCA). Due to the delayed diagnosis of left MCA stroke, it was too late to perform any neurovascular intervention. The commentary highlights the importance of timely use of stroke alert protocols, challenges with CT angiography in early acute ischemic stroke, and the importance of communication and collaboration between ED and neurology teams.
WebM&M Cases
Garima Agrawal, MD, MPH, Pouria Kashkouli, MD, MS, and and Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA |
This WebM&M describes a 78-year-old veteran with dementia-associated aggressive behavior who was hospitalized multiple times over several months for hypoxic respiratory failure and atrial fibrillation before being discharged to a skilled nursing facility. The advanced care planning team, in consultation with palliative care and ethics experts, determined that transition to hospice was appropriate. However, these recommendations were verbally communicated and not documented in the chart. The patient developed acute hypoxic respiratory failure the night prior to the planned transition to hospice, was re-admitted to the hospital, and passed away three weeks later at the hospital. The commentary discusses the importance of well-coordinated transitions of care and the importance of active communication and standardized documentation during palliative care transitions.
WebM&M Cases
Luciano Sanchez, PharmD, Hollie Porras, PharmD, BCPS, and Cathy Lammers, MD |
This WebM&M highlights two cases of patient safety events that occurred due to medication dosing related to diagnostic imaging. The commentary highlights the challenges of administering sedation for diagnostic imaging, the use of risk stratification to understand patient risk for oversedation, and strategies for appropriate monitoring and communication.
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