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August 24, 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

Chen Z, Gleason LJ, Sanghavi P. Med Care. 2022;60:775-783.
All nursing homes certified by the Centers for Medicaid & Medicare Services (CMS) are required to submit select patient safety data which is used to calculate quality ratings. This study compared seven years of self-reported pressure ulcer data with claims-based data for pressure ulcer-related hospital admissions. Similar to earlier research on self-reported falls data, correlations between the self-reported and claims-based data was poor. The authors suggest alternate methods of data collection may provide the public with more accurate patient safety information.
Griffey RT, Schneider RM, Todorov AA. Ann Emerg Med. 2022;80:528-538.
Trigger tools are a novel method of detecting adverse events. This article describes the location, severity, omission/commission, and type of adverse events retrospectively detected using the computerized Emergency Department Trigger Tool (EDTT). Understanding the characteristics of prior adverse events can guide future quality and safety improvement efforts.
Rehder KJ, Adair KC, Eckert E, et al. J Patient Saf. 2023;19:36-41.
Teamwork is an essential component of patient safety.  This cross-sectional study of 50,000 healthcare workers in four large US health systems found that the teamwork climate worsened during the COVID-19 pandemic. Survey findings indicate that healthcare facilities with worsening teamwork climate had corresponding decreases in other measured domains, including safety climate and healthcare worker well-being. The researchers suggest that healthcare organizations should proactively increase team-based training to reduce patient harm.
Chen Z, Gleason LJ, Sanghavi P. Med Care. 2022;60:775-783.
All nursing homes certified by the Centers for Medicaid & Medicare Services (CMS) are required to submit select patient safety data which is used to calculate quality ratings. This study compared seven years of self-reported pressure ulcer data with claims-based data for pressure ulcer-related hospital admissions. Similar to earlier research on self-reported falls data, correlations between the self-reported and claims-based data was poor. The authors suggest alternate methods of data collection may provide the public with more accurate patient safety information.
Griffey RT, Schneider RM, Todorov AA. Ann Emerg Med. 2022;80:528-538.
Trigger tools are a novel method of detecting adverse events. This article describes the location, severity, omission/commission, and type of adverse events retrospectively detected using the computerized Emergency Department Trigger Tool (EDTT). Understanding the characteristics of prior adverse events can guide future quality and safety improvement efforts.
Arkin L, Schuermann A, Penoyer D, et al. J Nurs Care Qual. 2022;37:319-326.
Nurses are responsible for several steps in the medication-use process, including preparation, administration, and monitoring of most medications. This study queried nurses working at a 10-hospital system in the southeastern United States about their attitudes, beliefs, and skills surrounding medication safety and error reporting. Survey responses indicate that nurses felt comfortable completing an incident report regarding an error and disclosing the error to another health care provider. There was some ambiguity around rating the severity of hypothetical errors.
Occelli P, Mougeot F, Robelet M, et al. J Patient Saf. 2022;18:415-420.
Understanding patient experience can provide key insights about safety culture. This qualitative study of 80 adult patients concluded that patients’ perspectives of surgical safety are closely tied to the degree of trust they have in their surgeons; this trust is based on the patient’s relationship with their surgeon, communication style, and the patient’s experience during perioperative consultation.
Kolbe M, Grande B, Lehmann-Willenbrock N, et al. BMJ Qual Saf. 2022;Epub Jul 28.
Debriefing is an effective method for improving individual, team, and system performance, and skilled facilitators can enhance the effectiveness of the debrief. Researchers analyzed 50 video-recorded debrief sessions to assess the interactions between debriefer and participants to identify the type of communication that resulted in increased participant reflection. Advocacy-inquiry prompted increased reflection.
Hurley VB, Boxley C, Sloss EA, et al. J Patient Saf Risk Manag. 2022;27:181-187.
Research has shown wide variation in error reporting by profession, with nurses reporting substantially more often than physicians. This study explored not only report rates by profession, but also across departments and event types. Results indicate physicians and technicians are more likely to report errors from across departmental boundaries , while nurses and physicians report a wider variety of error types.
Rehder KJ, Adair KC, Eckert E, et al. J Patient Saf. 2023;19:36-41.
Teamwork is an essential component of patient safety.  This cross-sectional study of 50,000 healthcare workers in four large US health systems found that the teamwork climate worsened during the COVID-19 pandemic. Survey findings indicate that healthcare facilities with worsening teamwork climate had corresponding decreases in other measured domains, including safety climate and healthcare worker well-being. The researchers suggest that healthcare organizations should proactively increase team-based training to reduce patient harm.
Sutherland A, Gerrard WS, Patel A, et al. BMJ Open Qual. 2022;11:e001708.
Smart pump software can improve medication safety but can also introduce patient safety hazards, such as alert fatigue. In this study, dose error reduction software (DERS) was implemented across two large UK National Health Service (NHS) institutes for one year. Findings indicate that compliance with DERS was 45%, but across one year of implementation, severe harm or death was avoided in up to 110 patients.
Prieto JM, Falcone B, Greenberg P, et al. J Surg Res. 2022;279:84-88.
Hospitalized children are vulnerable to patient safety risks. Using a large malpractice claims database, researchers found that a wide range of pediatric surgical specialties – including orthopedics, general surgery, and otolaryngology – are most frequently associated with malpractice lawsuits. The study identified several potentially modifiable factors (i.e., patient evaluations, technical performance, and communication) that can lead to improvements in pediatric surgical safety.

Garcia AD, Lopez X. AMA J Ethics. 2022;24(8):e753-e761. 

Implicit bias, discrimination, and stigmatization impact patient care. This article discusses unique care experience considerations for transgender people of color. It recommends actions individual clinicians can take to reduce inequalities, improve communications, and enhance patient-centeredness.
Olans RD, Olans RN, Marfatia R, et al. Jt Comm J Qual Patient Saf. 2022;48:552-558.
Inadequate or incorrect documentation of patient allergies can lead to patient harm. This commentary discusses factors contributing to penicillin allergy documentation errors within electronic heath record systems (EHRs) and how EHR alerts can be used to improve safety around penicillin allergies.
Moody A, Chacin B, Chang C. Curr Opin Anaesthesiol. 2022;35:465-471.
Hospital-acquired pressure injuries are considered a never event. This review presents strategies to prevent pressure injuries in the nonoperating room anesthesia (NORA) population (e.g., patients on ventilators). Proper positioning of the patient, with bolsters and padding, are illustrated.
Violato E. Adv Health Sci Educ Theory Pract. 2022;27:1177-1194.
Speaking up behaviors are a key indicator of psychological safety and a culture of safety. This article synthesizes the evidence on various aspects of speaking up behavior, including effective interventions to encourage speaking up, factors that positively influence speaking up, and the role of simulation training to develop speaking up skills.  
McKay C, Schenkat D, Murphy K, et al. Hosp Pharm. 2022;57:689-696.
Insulin is a high-alert medication due to heightened risk for serious patient harm if administered incorrectly. This review presents types of common errors (e.g., wrong patient, cross-contamination), pros and cons of potential dispensing strategies, and the impact of organizational factors (e.g., workflows, cost) on safe dispensing. Additionally, the authors make recommendations for dispensing, taking organization factors into account.
No results.

Bushwick S. Scientific American. August 1, 2022.

Sepsis identification is challenging, and delays can be deadly. This article discusses how an artificial intelligence program at one hospital over two years contributed to more timely sepsis diagnosis and treatment.

Jefs L, Kuluski K, MacLaurin A, et al. Ottawa, Ontario, Canada: Healthcare Excellence Canada; 2022.

Patient engagement in safety improvement goes beyond activities related to direct care. This report highlights the value that patient perspectives bring to the effort to translate the results of a national measures program to strengthen strategic progress and patient and family program involvement.

Integrated Health Services. Geneva, Switzerland: World Health Organization; 2022. ISBN: 9789240055094.

The COVID-19 pandemic created new risks and acerbated existing risks across all areas of health care practice that challenge patient safety. This review examines how COVID impacted diagnostic, treatment, and care procedures in a systemic context.

Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.

Medication errors associated with surgery and other invasive procedures can result in patient harm. This 10-element guidance suggests effective practices to address identified weaknesses in perioperative and procedural medication processes. Recommendations provided cover topics such as drug labeling, communication, and risk management.

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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