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January 11, 2023 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

Heesen M, Steuer C, Wiedemeier P, et al. J Patient Saf. 2022;18:e1226-e1230.
Anesthesia medications prepared in the operating room are vulnerable to errors at all stages of medication administration, including preparation and dilution. In this study, anesthesiologists were asked to prepare the mixture of three drugs used for spinal anesthesia for cesarean section. Results show deviation from the expected concentration and variability between providers. The authors recommend all medications be prepared in the hospital pharmacy or purchased pre-mixed from the manufacturer to prevent these errors. 
Lucas SR, Pollak E, Makowski C. J Healthc Risk Manag. 2022;Epub Dec 4.
Medical errors that receive widespread media attention frequently spur health systems to reexamine their own culture and practices to prevent similar errors. This commentary describes one health system’s effort to identify and improve the system factors (systems, processes, technology) involved in the error. The action plan proposed by this project includes ensuring a just culture so staff feel empowered to report errors and near-misses; regularly review and improve medication delivery systems; build resilient medication delivery systems; and, establish methods of investigations.
Rodgers S, Taylor AC, Roberts SA, et al. PLoS Med. 2022;19:e1004133.
Previous research found that a pharmacist-led information technology intervention (PINCER) reduced dangerous prescribing (i.e., medication monitoring and drug-disease errors) among a subset of primary care practices in the United Kingdom (UK). This longitudinal analysis examined the impact of the PINCER intervention after implementation across a large proportion of general practices in one region in the UK. Researchers found the PINCER intervention decreased dangerous prescribing by 17% and 15% at 6-month and 12-month follow-ups, particularly among dangerous prescribing related to gastrointestinal bleeding.
Heesen M, Steuer C, Wiedemeier P, et al. J Patient Saf. 2022;18:e1226-e1230.
Anesthesia medications prepared in the operating room are vulnerable to errors at all stages of medication administration, including preparation and dilution. In this study, anesthesiologists were asked to prepare the mixture of three drugs used for spinal anesthesia for cesarean section. Results show deviation from the expected concentration and variability between providers. The authors recommend all medications be prepared in the hospital pharmacy or purchased pre-mixed from the manufacturer to prevent these errors. 
Bloomer A, Wally M, Bailey G, et al. Geriatr Orthop Surg Rehabil. 2022;13:215145932211256.
Opioid use by older adults increases the risk of falls. This study examined electronic health record data to determine the proportion of older adults presenting to the emergency room or urgent care due to a fall who receive an opioid prescription, particularly those with at least one risk factor for misuse. Nearly one third of patients received a prescription for an opioid and/or benzodiazepine, and 11% had at least one risk factor for misuse.
Skead C, Thompson LH, Kuk H, et al. Crit Care Res Pract. 2022;2022:4815734.
After-hours and weekend admissions to the hospital and intensive care units (ICU) have been linked to poor outcomes. This retrospective analysis compared outcomes among adult patients with daytime versus nighttime ICU admissions at one large Canadian medical center in between 2011 and 2015. Researchers found that overall mortality, but not ICU mortality, was higher among daytime admissions.
Zigman Suchsland M, Kowalski L, Burkhardt HA, et al. Cancers (Basel). 2022;14:5756.
Delayed diagnosis and treatment of cancer is a serious patient safety problem. This retrospective study including 711 patients diagnosed with lung cancer used electronic health records and natural language processing (NLP) to identify relevant signs and symptoms in the two years prior to their cancer diagnosis. Researchers found that NLP can identify signs and symptoms associated with lung cancer over a year prior to diagnosis.
Pado K, Fraus K, Mulhem E, et al. J Clin Psychol Med Settings. 2022;Epub Dec 12.
Medical errors may lead to feelings of distress for clinicians, but these errors can also be an opportunity for growth. This study used the Second Victim Experience and Support Tool (SVEST) and the Posttraumatic Growth Inventory to assess the extent, if any, of growth following a medical mishap. Rumination and the impact of the medical mishap were associated with distress among both physicians and nurses. The impact of the event was associated with growth in nurses, but no factor was associated with growth in physicians.
Rodgers S, Taylor AC, Roberts SA, et al. PLoS Med. 2022;19:e1004133.
Previous research found that a pharmacist-led information technology intervention (PINCER) reduced dangerous prescribing (i.e., medication monitoring and drug-disease errors) among a subset of primary care practices in the United Kingdom (UK). This longitudinal analysis examined the impact of the PINCER intervention after implementation across a large proportion of general practices in one region in the UK. Researchers found the PINCER intervention decreased dangerous prescribing by 17% and 15% at 6-month and 12-month follow-ups, particularly among dangerous prescribing related to gastrointestinal bleeding.
Balshi AN, Al-Odat MA, Alharthy AM, et al. PLoS ONE. 2022;17:e0277992.
Many hospitals have implemented rapid response teams (RRT) that are activated when a patient starts exhibiting prespecified criteria to prevent adverse outcomes. This before and after study compared nurse-activated RRT and automated activation. Non-invasive bedside sensors monitored patients’ vital signs and automatically sent alerts to the RRT based on prespecified clinical signs. Compared to the before period, there were lower rates of CPR, higher rates of successful CPR, shorter lengths of stay, and lower hospital mortality.
Pratt BR, Dunford BB, Vogus TJ, et al. Health Care Manage Rev. 2022;48:14-22.
Organizational pressures sometimes lead to redeployment or task reallocation such as shifting infusion tasks from specialty nurse teams to generalist nurses. This survey of nurses in the United States found that infusion task reallocation led to increased job demands and reduced resources, thereby contributing to lower perceived organizational safety.
Cohen AL, Sur M, Falco C, et al. Diagnosis (Berl). 2022;9:476-484.
Clinical reasoning is now a common method to improve diagnostic decision making, and several tools have been developed to assess learners’ clinical reasoning. In this study, hospital faculty and pediatric interns used the Assessment of Reasoning Tool (ART) to assess, teach, and guide feedback on the interns’ clinical reasoning. Faculty and interns report the ART framework was highly structured, specific, formative, and facilitated goal setting.
Lucas SR, Pollak E, Makowski C. J Healthc Risk Manag. 2022;Epub Dec 4.
Medical errors that receive widespread media attention frequently spur health systems to reexamine their own culture and practices to prevent similar errors. This commentary describes one health system’s effort to identify and improve the system factors (systems, processes, technology) involved in the error. The action plan proposed by this project includes ensuring a just culture so staff feel empowered to report errors and near-misses; regularly review and improve medication delivery systems; build resilient medication delivery systems; and, establish methods of investigations.
Danielson B. Health Affairs. 2022;41:1681-1685.
Racism is a patient safety issue that is gaining the increased attention needed to clarify, understand, and reduce its impact. This commentary draws from a primary care pediatrician’s experience to illustrate how latent systemic racism influences decision making to affect a Black mother’s ability to care for her child with complex care needs.
Smith WR, Valrie C, Sisler I. Hematol Oncol Clin North Am. 2022;36:1063-1076.
Racism exacerbates health disparities and threatens patient safety. This article summarizes the relationship between structural racism and health disparities in the United States and highlights how racism impacts health care delivery and health outcomes for patients with sickle cell disease.

REPAIR Project Steering Committee. Acad Med. 2022;97(12):1753-1759. 

The REPAIR (REParations and Anti-Institutional Racism) Project at the University of California, San Francisco, aims to repair racial injustices in medical care and research. This article discusses the development of the initiative, the three annual themes (reparations, abolition, decolonization), and outcomes from its first year.
Erstad BL, Romero AV, Barletta JF. Am J Health Syst Pharm. 2022;Epub Oct 4.
Weight-based dosing is vulnerable to error due to inaccurate estimation of body weight, use of metric vs. non-metric units, or patients being underweight or overweight. This commentary suggests strategies for reducing weight- and size-based dosing errors including reduction in reliance on estimated body weight, standardizing descriptor (e.g., body mass index), limiting options in the electronic health record (EHR), and integrating complex calculations into the EHR.
Thusini S’thembile, Milenova M, Nahabedian N, et al. BMC Health Serv Res. 2022;22:1492.
Health systems often consider return on investment (ROI) when considering implementation of quality improvement and patient safety interventions (i.e., costs saved by preventing medical errors or improving quality of care). This systematic review explored how ROI concepts have been used in studies assessing large-scale quality improvement programs.

Collaborative for Accountability and Improvement.  January 26, 2023, 2:00-3:00 PM (eastern).

Root cause analysis (RCA) is a recognized approach to examining failures by identifying causal factors to define improvement effort. This session will discuss challenges to the effective use of RCA results and examine an approach to present them that supports effective improvement action.

Agency for Healthcare Research and Quality. January 24, 2023, 1:00 – 2:00 PM (eastern).

Workplace safety became more apparent during the COVID pandemic as an essential component to support effective and safe care provision. This session will introduce the AHRQ Workplace Safety Supplemental Item Set for use with the Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey that examines staff perceptions of workplace safety. Background on the importance of workplace safety in nursing homes, results from a pilot test in 48 nursing homes, and one organization’s experience with the survey will be shared.
Press Release/Announcement

Agency for Healthcare Research and Quality.

Telemedicine efforts harbor both risk and reward to patients and providers. The AHRQ Safety Program for Telemedicine is a national effort to develop and implement a bundle of evidence-based interventions designed to improve telemedicine care in two settings—the cancer diagnostic process and antibiotic use. To test the bundle of interventions, the program will involve two cohorts of healthcare professionals who utilize telemedicine as a care delivery model. It is an 18-month program, beginning in June 2023, that seeks to improve the cancer diagnostic process for patients who receive some or all of their care through telemedicine. Recruitment webinars start in late January and run through early May 2023; the antibiotic use cohort will begin recruitment in December 2023. 

Pharmacy Practice News Special Edition. December 13, 2022: 43-54.

Medication errors continue to occur despite long-standing efforts to reduce them. This article summarizes types of errors submitted to the Institute for Safe Medication Practices reporting program in 2021. The piece discusses the medications involved, recommendations for improvement, and technologies to be employed to minimize error occurrence.

This Month’s WebM&Ms

WebM&M Cases
Christian Bohringer, MBBS and Luis Godoy, MD |
A 62-year-old Spanish-speaking woman presented to the pre-anesthesia area for elective removal of a left thigh lipoma. Expecting a relatively simple outpatient operation, the anesthesiologist opted not to use a Spanish language translator and performed a quick pre-anesthesia evaluation, obtaining her history from the medical record. Unknown to the anesthesiologist, the patient was trying to communicate to him that she had undergone jaw replacement surgery and that her mouth opening was therefore anatomically limited. During the procedure, the anesthesiologist realized he would need to ventilate the patient, but his view was severely limited, and he was unable to visualize the airway sufficiently for intubation. Eventually the patient was intubated, although both of her central maxillary incisors were dislodged in the process, and she required dental implants to replace the two dislodged teeth. The commentary discusses the importance of conducting preoperative assessments in the patient’s own language and the role of medical interpreting services, as well as approaches to manage patients with difficult airways.  
WebM&M Cases
Mark Fedyk, PhD, Nathan Fairman, MD, MPH, Patrick S. Romano, MD, MPH, John MacMillan, MD, and Monica Miller, RN, MS, CCRN |
A 65-year-old man with metastatic liver disease presented to the hospital with worsening abdominal pain after a partial hepatectomy and development of a large ventral hernia. Imaging studies revealed perforated diverticulitis. A goals-of-care discussion was led by the palliative care service; the patient and his designated decision-makers chose to pursue non-operative management of diverticulitis. The condition worsened, signaling failure of non-operative management; following his wishes, he transitioned to comfort-focused end-of-life care. Shortly after this transition, the patient became unresponsive and only showed non-verbal signs of pain. The care team disagreed about how to best manage the patient’s pain and the family expressed anger, anxiety, and frustration that he remained in pain. After 5 days of continued unresponsiveness and non-verbal signs of pain, the patient died. The palliative care team spent many hours with the family helping them to manage their grief and dissatisfaction. The commentary highlights a decision-making framework to consider when creating and implementing care plans (including the importance of patient preferences) and how care teams should handle disagreement with care plans.
WebM&M Cases
Naileshni S. Singh, MD |
A 63-year-old woman was admitted to a hospital for anterior cervical discectomy (levels C4-C7) and plating for cervical spinal stenosis under general anesthesia. The operation was uneventful and intraoperative neuromonitoring was used to help prevent spinal cord and peripheral nerve injury. During extubation after surgery, the anesthesia care provider noticed a large (approximately 4-5 cm) laceration on the underside of the patient’s tongue, with an associated hematoma. This finding was attributed to the fact that the inexperienced anesthesia care provider was unaware of the fact that motor evoked potentials can cause an anesthetized patient’s jaw to clench quite strongly, and thus had not placed a bite block in the patient's mouth. The patient's tongue laceration resulted in pain and difficulty speaking and the patient was taken back to the operating room so that her tongue laceration could be repaired.

This Month’s Perspectives

Michelle Schreiber photograph
Interview
We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services.
Ellen Deutsch photograph
Interview
Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS is a Medical Officer in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality. Dr. Deutsch is a pediatric otolaryngologist and has vast experience in simulation and resilience engineering. We spoke with her about resilient healthcare and how resilient engineering principles are applied to improve patient safety.
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