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July 13, 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

Dregmans E, Kaal AG, Meziyerh S, et al. JAMA Netw Open. 2022;5:e2218172.
Inappropriate antibiotic prescribing can result in patient harm and costly antibiotic-resistant infections. Health record review of 1,477 patients admitted from the emergency department for suspected bacteremia infection revealed that 11.6% were misdiagnosed at infection site, and 3.1% did not have any infection. Misdiagnosis was not associated with worse short-term clinical outcomes but was associated with potentially inappropriate broad-spectrum antibiotic use.
Fenton JJ, Magnan E, Tseregounis IE, et al. JAMA Netw Open. 2022;5:e2216726.
Adverse events associated with long-term opioid therapy have led to recommendations for dose tapering for patients with chronic pain. This study assessed the long-term risks of overdose and mental health crisis as a result of dose tapering. Consistent with earlier research on short-term risks, results indicate that opioid tapering is associated with increased risk of adverse events up to 24 months after initiation of tapering.
Thirsk LM, Panchuk JT, Stahlke S, et al. Int J Nurs Stud. 2022;133:104284.
Biases in healthcare can compromise decision-making and lead to diagnostic errors and delays in diagnosis. This scoping review examines cognitive and implicit biases in nursing care. The authors found a breadth of evidence examining the presence of cognitive and implicit biases in nursing but identified limited evidence evaluating effective debiasing interventions.
Dregmans E, Kaal AG, Meziyerh S, et al. JAMA Netw Open. 2022;5:e2218172.
Inappropriate antibiotic prescribing can result in patient harm and costly antibiotic-resistant infections. Health record review of 1,477 patients admitted from the emergency department for suspected bacteremia infection revealed that 11.6% were misdiagnosed at infection site, and 3.1% did not have any infection. Misdiagnosis was not associated with worse short-term clinical outcomes but was associated with potentially inappropriate broad-spectrum antibiotic use.
Makic MBF, Stevens KR, Gritz RM, et al. Appl Clin Inform. 2022;13:621-631.
Many interventions targeting healthcare-acquired condition reduction and prevention target a single condition, rather than the risks of multiple conditions. This proof-of-concept study discusses clinician feedback on a proposed dashboard to enhance clinicians’ management combining the risks of multiple conditions (catheter-associated urinary tract infections, pressure injuries, and falls).
Barnes T, Fontaine T, Bautista C, et al. J Patient Saf. 2022;18:e704-e713.
Patient safety event taxonomies provide a standardized framework for data classification and analysis. This taxonomy for inpatient psychiatric care was developed from existing literature, national standards, and content experts to align with the common formats used by the institution’s event reporting system. Four domains (provision of care, patient actions, environment/equipment, and safety culture) were identified, along with categories, subcategories, and subcategory details.
Madigan C, Way KA, Johnstone K, et al. J Safety Res. 2022;81:203-215.
Leadership engagement in safety is essential to implementing sustainable change. This qualitative study found that rational persuasion and legitimating were the most frequently used and certain factors – such as organizational culture, safety beliefs, and leadership style – can impact how safety professionals influence managers making safety decisions in healthcare settings. The authors discuss the importance of both technical and non-technical skills to enhance influence among safety professionals.
Atkinson MK, Benneyan JC, Bambury EA, et al. Health Care Manage Rev. 2022;47:E50-E61.
Patient safety learning laboratories (PSLL) encourage a cross-disciplinary, collaborative approach to problem solving. This study reports on how a learning ecosystem supported the success of three distinct PSLLs. Qualitative and quantitative results reveal four types of alignment and supporting practices that contribute to the success of the learning laboratories.
Gupta K, Szymonifka J, Rivadeneira NA, et al. Jt Comm J Qual Patient Saf. 2022;48:492-496.
Analysis of closed malpractice claims can be used to identify potential safety hazards in a variety of clinical settings. This analysis of closed emergency department malpractice claims indicates that diagnostic errors dominate, and clinical judgment and documentation categories continue to be associated with a higher likelihood of payout. Subcategories and contributing factors are also discussed.
Kepner S, Adkins JA, Jones RM. Patient Safety. 2022;4:6-17.
Residents at long-term care facilities are at increased risk for healthcare-associated infections. Using 2021 data from the Pennsylvania Patient Safety Reporting System (PA-PRS), this study characterized healthcare-associated infections (HAIs) occurring at long-term care facilities. Researchers found that HAIs occurring at long-term care facilities decreased, but it is unknown whether this is reflective of fewer infections or poor reporting practices at long-term care facilities, or both.
Fenton JJ, Magnan E, Tseregounis IE, et al. JAMA Netw Open. 2022;5:e2216726.
Adverse events associated with long-term opioid therapy have led to recommendations for dose tapering for patients with chronic pain. This study assessed the long-term risks of overdose and mental health crisis as a result of dose tapering. Consistent with earlier research on short-term risks, results indicate that opioid tapering is associated with increased risk of adverse events up to 24 months after initiation of tapering.
Hoff JJ, Zimmerman A, Tupetz A, et al. Prehosp Emerg Care. 2022;Epub May 6.
Involvement in serious adverse events can cause clinicians to feel significant and ongoing emotional trauma. Interviews with eight emergency medical service (EMS) personnel revealed self-perceived errors were more likely to result in feelings of shame, and a positive safety culture supported recovery and resilience.
Ibrahim SA, Reynolds KA, Poon E, et al. BMJ. 2022;377:e063064.
Accreditation programs such as The Joint Commission are intended to improve patient safety and quality. Investigators evaluated the evidence base for 20 actionable standards issued by The Joint Commission. Standards were classified by the extent to which they were supported by evidence, evidence quality ratings, and the strength of the recommendation.
Loerbroks A, Vu-Eickmann P, Dreher A, et al. Int J Environ Res Public Health. 2022;19:6690.
Work engagement may be a beneficial counterpart to burnout among health care workers. This cross-sectional study explored the association between work engagement scores with self-reported concerns about having made medical errors among medical assistants in Germany.
Gong Y. Stud Health Technol Inform. 2022;291:133-150.
Reporting incidents and errors is a cornerstone of patient safety improvement efforts, but challenges remain, including low quality of reports and low rates of reporting. This article discusses the technological challenges of incident reporting and offers recommendations to improve usability in future reporting systems.
Thirsk LM, Panchuk JT, Stahlke S, et al. Int J Nurs Stud. 2022;133:104284.
Biases in healthcare can compromise decision-making and lead to diagnostic errors and delays in diagnosis. This scoping review examines cognitive and implicit biases in nursing care. The authors found a breadth of evidence examining the presence of cognitive and implicit biases in nursing but identified limited evidence evaluating effective debiasing interventions.
Leland NE, Lekovitch C, Martínez J, et al. J Appl Gerontol. 2022;41:2187-2196.
Patient falls can be reduced through effective quality and safety strategies. This scoping review discusses common post-acute care intervention domains to reduce falls for older adults (e.g., staff education, individualized risk profiles) and study variability in the extent to which these domains are addressed.  
No results.

Infect Control Hosp Epidemiol. 2022.

Health care–associated infections (HAIs) affect patients both during and after hospitalization. The use of patient safety methods as well as traditional infection control practices has resulted in significant successes in curbing HAIs such as central-line bloodstream infections. This set of practice guidelines will be developed and disseminated over the course of 2022 to summarize preemptive actions and implementation strategies for prevention of HAIs.

Washington, DC: VA Office of the Inspector General; June 28, 2022. Report No 21-03349-186.

 Cancer test communication failures can contribute to physical, emotional, and financial patient harm. This report examines missed opportunities made by multiple clinicians involved in the care of a patient with prostate cancer who then died from metastasized disease Seven recommendations are included for improving abnormal test result communication and error management at the facility.

Moss LD. Clinical Advisor. June 29, 2022.

Health disparities perpetuated by structural racism degrade patient safety. This article discusses the influence of implicit biases on care delivery and highlights the increased interest and research being generated to improve understanding and initiative design to reduce the impact of implicit bias on care.
Audiovisual Presentation

National Patient Safety Board. 2021-2022.

Patient safety expertise builds on a wide range of subjects to inform progress. This webinar series features discussions on topics spanning concerns that impact effective care delivery such as peer evaluation, systemic failures, human factors, and big data. A June 2022 discussion guide accompanies the series to support conversation and reflection.

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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