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August 17, 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

Chang ET, Newberry S, Rubenstein LV, et al. JAMA Network Open. 2022;5:e2224938.
Patients with chronic or complex healthcare needs are at increased risk of adverse events such as rehospitalization. This paper describes the development of quality measures to assess the safety and quality of primary care for patients with complex care needs at high risk of hospitalization or death. The expert panel proposed three categories (assessment, management, features of healthcare), 15 domains, and 49 concepts.
Marsh KM, Turrentine FE, Knight K, et al. Ann Surg. 2022;275:1067-1073.
Having standardized definitions and classifications of errors allows researchers to better understand potential causes and interventions for improvement. This systematic review identified six broad error categories, 13 definitions of error, and 14 study methods in the surgical error literature. Development and use of a common definition and taxonomy of errors will provide a more accurate indication of the prevalence of surgical error rates.
Neely J, Sampath R, Kirkbride G, et al. J Correct Health Care. 2022;28:141-147.
Incarcerated individuals face unique patient safety threats. Based on a collaboration between the Illinois Department of Corrections and the University of Illinois College of Nursing, this article describes a plan for improving the quality and safety of healthcare for the state’s incarcerated population.  
McDade JE, Olszewski AE, Qu P, et al. Front Pediatr. 2022;10:872060.
Language barriers can place patients at increased risk for adverse events and near misses. This retrospective cohort study found that rapid response team events for non-English speaking pediatric patients are more likely to result in transfer to the intensive care unit compared to English-speaking patients. However, researchers also found that increased use of interpreters can contribute to improved outcomes.  
Ivanovic V, Assadsangabi R, Hacein-Bey L, et al. Clin Radiol. 2022;77:607-612.
Radiological interpretation errors can result in unnecessary additional tests, wrong treatment and delayed diagnosis. This study explored the correlation between neuroradiologists’ diagnostic errors and attendance at institutional tumor boards. Results show that higher attendance at tumor boards was strongly correlated with lower diagnostic error rates. The researchers recommend increased and continuous attendance at tumor boards for all neuroradiologists.
Patrician PA, Bakerjian D, Billings R, et al. Nurs Outlook. 2022;70:639-650.
Clinician well-being has important implications for patient safety and quality of healthcare delivery. In this study, researchers used a concept analysis to identify attributes of nurse well-being at the individual level (e.g., satisfaction, compassion) and organizational/community level (e.g., teamwork, pride in work). These findings can support the development of a standardized definition of nurse well-being to guide future research and policy considerations around well-being and burnout.
Packer MDC, Ravinsky E, Azordegan N. Am J Clin Pathol. 2022;157:767-773.
Studies have shown diagnostic discordance in evaluation of surgical pathology specimens. In this study, pathologists and pathology residents were asked to diagnose surgical pathology or cytopathology cases and provide a diagnosis. Most respondents provided the correct diagnosis for most of the cases; 35% of cases were wholly or partially misdiagnosed. Educational and process changes (e.g., requiring subspecialist over-read for some diagnoses) were implemented in the pathology department in response, resulting in substantial improvement in error rates.
Neely J, Sampath R, Kirkbride G, et al. J Correct Health Care. 2022;28:141-147.
Incarcerated individuals face unique patient safety threats. Based on a collaboration between the Illinois Department of Corrections and the University of Illinois College of Nursing, this article describes a plan for improving the quality and safety of healthcare for the state’s incarcerated population.  
Chang ET, Newberry S, Rubenstein LV, et al. JAMA Network Open. 2022;5:e2224938.
Patients with chronic or complex healthcare needs are at increased risk of adverse events such as rehospitalization. This paper describes the development of quality measures to assess the safety and quality of primary care for patients with complex care needs at high risk of hospitalization or death. The expert panel proposed three categories (assessment, management, features of healthcare), 15 domains, and 49 concepts.
Lambert BL, Schiff GD. J Am Coll Clin Pharm. 2022;5:981-987.
In the wake of the criminal conviction of a nurse involved in a medical error, numerous organizations and institutions have warned of the negative impact it could have on learning and error disclosure. This commentary presents strategies to reduce the risk of criminal prosecution for pharmacists, including education of prosecutors and expert witnesses and minimization of overrides and workarounds.
Sabin JA. N Engl J Med. 2022;387:105-107.
Implicit bias in clinicians can result in diagnostic errors and poor patient outcomes. This commentary outlines steps that individual clinicians, as well as healthcare systems, can take to reduce implicit bias and the resulting harm to patients.
Zipperer L, Ryan R, Jones B. J Patient Saf Risk Manag. 2022;27:201-208.
Implicit biases and stigma can negatively impact health care provided to patients with substance use disorders such as alcohol use disorder (AUD). This narrative review concluded that patients with AUD are frequently undiagnosed and not appropriately referred for treatment or treated. The authors cite barriers to effective care for patients with AUD, including poor integration and coordination between medical care and behavioral health care in the United States.
Marsh KM, Turrentine FE, Knight K, et al. Ann Surg. 2022;275:1067-1073.
Having standardized definitions and classifications of errors allows researchers to better understand potential causes and interventions for improvement. This systematic review identified six broad error categories, 13 definitions of error, and 14 study methods in the surgical error literature. Development and use of a common definition and taxonomy of errors will provide a more accurate indication of the prevalence of surgical error rates.
Dionisi S, Giannetta N, Liquori G, et al. Healthcare (Basel). 2022;10:1221.
Medication errors are a global patient safety concern, particularly in high-risk areas like the intensive care unit. This umbrella review synthesizes medication interventions into two areas: systems (e.g., smart pumps) and processes (e.g., medication review). The authors highlight the importance of using multiple strategies when working to improve medication safety in the ICU.
Ramsey L, McHugh SK, Simms-Ellis R, et al. J Patient Saf. 2022;18:e1203-e1210.
Patients and families can contribute unique insights into medical errors. This qualitative evidence review concluded that patients and families value involvement in patient safety incident investigations but highlight the importance of addressing the emotional aspects of care (e.g., timely apology, prioritizing trust and transparency). Healthcare staff perceived patient and family involvement in investigations to be important, but cited several barriers (e.g., staff turnover, fears of litigation) to effective investigations.
van Marum S, Verhoeven D, de Rooy D. J Patient Saf. 2022;18:e1067-e1075.
Underutilization of error reporting systems may be due to a variety of factors, including a culture of fear or blame. This systematic review identified three types of factors influencing trust in error reporting – organizational factors (e.g., management style, focus on safety instead of punitive measures, leadership walk-rounds, established incident reporting systems), team factors (e.g., clearly defined team roles, relationships among teammates), and experience (e.g., knowledge of incident reporting systems, minimizing fear of shame or blame).
Bail K, Gibson D, Acharya P, et al. Int J Med Inform. 2022;165:104824.
A range of health information technologies (e.g., computerized provider order entry) is used in patient care. This integrated review identified 95 papers on the impact of health information technology on the outcomes of residents in older adult care homes. Most papers focused on usability and implementation of technology and the perceptions of staff. Fewer focused on patient quality or safety outcomes.
No results.

US Senate Finance Committee. 117th Cong (2021-2022). August 3, 2022.

Organ transplantation processes require reliable communication and technical expertise to ensure safety for organ delivery and patient care. This hearing discussed the findings of a United States Senate investigation into waste and harm in the US organ transplant system. Blood-type mistakes, transport failures, and process challenges were amongst the problems discussed.

Feibel C. Consider This. National Public Radio. August 3, 2022. 

Maternal complications risk the health of both mothers and babies, and a variety of circumstances create challenges to this complex care process. This article describes delays in care for a pregnant patient due to legal and policy concerns that threatened the life of the mother.

Manojlovich M, Krein SL, Kronick SL, et al. Rockville, MD: Agency for Healthcare Research and Quality; August 2022. AHRQ Publication No. 22-0026-2-EF.

Nurses are increasingly discussed as diagnostic team members. The knowledge of the team as a unit, or distributed cognition, is considered as an asset to diagnosis that rests on relationships between nurses, physicians, and patients. This issue brief is part of a series on diagnostic safety.

Clark C. MedPage Today. August 4. 

Consistent policy supporting transparency of hospital safety records is important for patients as they make provider choices. This article highlights a shift made to retain reporting requirements in the Hospital-Acquired Condition Reduction Program (HACRP) that had been threatened due to the influence of the COVID pandemic on data integrity.

This Month’s WebM&Ms

WebM&M Cases
Spotlight Case
Kevin J. Kelly, MD |
A 65-year-old female with a documented allergy to latex underwent surgery for right-sided Zenker’s diverticulum. Near the conclusion of surgery, a latex Penrose drain was placed in the neck surgical incision. The patient developed generalized urticaria, bronchospasm requiring high airway pressures to achieve adequate ventilation, and hypotension within 5 minutes of placement of the drain. The drain was removed and replaced with a silicone drain. Epinephrine and vasopressors were administered post-operatively and the patient’s symptoms resolved. The commentary discusses risk factors and consequences of latex allergy in hospital and operating room settings, common latex products that trigger allergic reactions  and hospital safety practices that can limit the risk of latex exposure.
WebM&M Cases
Spotlight Case
Anamaria Robles, MD, and Garth Utter, MD, MSc |
A 49-year-old woman was referred by per primary care physician (PCP) to a gastroenterologist for recurrent bouts of abdominal pain, occasional vomiting, and diarrhea. Colonoscopy, esophagogastroduodenoscopy, and x-rays were interpreted as normal, and the patient was reassured that her symptoms should abate. The patient was seen by her PCP and visited the Emergency Department (ED) several times over the next six months. At each ED visit, the patient’s labs were normal and no imaging was performed. A second gastroenterologist suggested a diagnosis of intestinal ischemia to the patient, her primary gastroenterologist, her PCP, and endocrinologist but the other physicians did not follow up on the possibility of mesenteric ischemia. On another ED visit, the second gastroenterologist consulted a surgeon, and a mesenteric angiogram was performed, confirming a diagnosis of mesenteric ischemia with gangrenous intestines. The patient underwent near-total intestinal resection, developed post-operative infections requiring additional operations, experienced cachexia despite parenteral nutrition, and died of sepsis 3 months later.  The commentary discusses the importance of early diagnosis of mesenteric ischemia and how to prevent diagnostic errors that can impede early identification and treatment.
WebM&M Cases
Samson Lee, PharmD, and Mithu Molla, MD, MBA |
This WebM&M highlights two cases where home diabetes medications were not reviewed during medication reconciliation and the preventable harm that could have occurred. The commentary discusses the importance of medication reconciliation, how to compile the ‘best possible medication history’, and how pharmacy staff roles and responsibilities can reduce medication errors.

This Month’s Perspectives

Francoise A. Marvel
Interview
Francoise A. Marvel, MD, is an assistant professor of medicine within the Division of Cardiology at Johns Hopkins Hospital, codirector of the Johns Hopkins Digital Health Innovation Lab, and the chief executive officer (CEO) and cofounder of Corrie Health. We spoke with her about the emergence of application-based tools used for healthcare and the patient safety issues surrounding the use of such tools.
Perspectives on Safety
This piece focuses on the emergence and use of digital applications (apps), app-based products and devices for healthcare, and the implications for patient safety.
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