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July 26, 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

Fanikos J, Tawfik Y, Almheiri D, et al. Am J Med. 2023;136:927-936.
Anticoagulants are high-risk medications in both outpatient and inpatient settings. This study compared two time periods, both before and after implementation of anticoagulant safety programs, to assess changes in type, severity, root cause, and outcomes of adverse events in hospitalized patients. Despite numerous changes in procedures and technology, adverse events increased in the post-implementation period.
Newman-Toker DE, Nassery N, Schaffer AC, et al. BMJ Qual Saf. 2023;Epub Jul 17.
Previous research has found that three diseases (vascular events, infections, and cancers) account for approximately 50% of all serious misdiagnosis-related harm. Based on a sample of 21.5 million US hospital discharges, the authors estimated that 795,000 adults in the US experience serious misdiagnosis-related harm (permanent morbidity or mortality) attributable to these three disease categories each year.
Stierman EK, O'Brien BT, Stagg J, et al. Qual Manag Health Care. 2023;32:177-188.
Maternal morbidity and mortality remain a significant problem in U.S. health care. This article describes Texas and Oklahoma’s adoption of a perinatal quality improvement initiative, including the implementation of the Alliance for Innovation of Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units. Findings suggest that adoption of initiative components varies across obstetric units; the majority of units had standardized processes for serious events (obstetric hemorrhage, massive transfusion, severe hypertension) but fewer units offered regular training on effective teamwork and communication for their staff.
Fanikos J, Tawfik Y, Almheiri D, et al. Am J Med. 2023;136:927-936.
Anticoagulants are high-risk medications in both outpatient and inpatient settings. This study compared two time periods, both before and after implementation of anticoagulant safety programs, to assess changes in type, severity, root cause, and outcomes of adverse events in hospitalized patients. Despite numerous changes in procedures and technology, adverse events increased in the post-implementation period.
Jarrett P, Keogh S, Roberts JA, et al. Intensive Crit Care Nurs. 2023;77:103403.
As with all medications, delays in or underdosing of antimicrobials can result in unnecessarily long hospital stays. This study found that discarded antibiotic vials in the intensive care unit (ICU) contained residual drug remaining in the vial (median 3.7% error). This finding suggests patients may not be receiving the full prescribed dose.
Hovda T, Larsen M, Romundstad L, et al. Eur J Radiol. 2023;165:110913.
Timely cancer diagnosis remains an important area for improvement. Using a national breast cancer registry, researchers reread negative screening mammograms of women diagnosed with breast cancer in the two years following the screening. Screening mammograms were then rated as true negative (i.e., no cancer could be detected) or missed (i.e., signs of cancer were visible but missed). Among women with screen-detected or interval cancer, most initial screening mammograms did not show visible signs of cancer.
Newman-Toker DE, Nassery N, Schaffer AC, et al. BMJ Qual Saf. 2023;Epub Jul 17.
Previous research has found that three diseases (vascular events, infections, and cancers) account for approximately 50% of all serious misdiagnosis-related harm. Based on a sample of 21.5 million US hospital discharges, the authors estimated that 795,000 adults in the US experience serious misdiagnosis-related harm (permanent morbidity or mortality) attributable to these three disease categories each year.
Issacs AN, Raymond A, Kent B. Contemp Nurse. 2023;59:202-213.
Despite widespread improvement efforts, medication administration errors (MAE) remain a patient safety problem. In this study, nurses at one Australian hospital provided a reflection as to why they believed an MAE occurred and these reflections were subsequently analyzed using a human factors framework. Individual characteristics, nature of the work, and physical environment factors were identified as contributing to MAE and represent areas for improvement.
Olin K, Klinga C, Ekstedt M, et al. BMC Health Serv Res. 2023;23:651.
The operating room is a high-risk environment involving complex tasks. This study used cognitive task analysis (CTA) to explore how anesthesia nurses and anesthesiologists manage complex everyday situations during intraoperative care processes. Findings underscore the importance of available resources, team composition, and non-technical skills (NTS) for managing complex daily work and promoting patient safety.
Dietl JE, Derksen C, Keller FM, et al. Front Psychol. 2023;14:1164288.
Psychological safety can support high-quality teamwork and communication. This article reports on perceived patient and psychological safety following an interprofessional obstetrical communication and psychological safety training as part of the TeamBaby research project. After the training, perceived patient safety risks were lower.

Peard LM, Teplitsky S, Annabathula A, et al. Can J Urol. 2023;30(2):11467-11472.

Root cause analysis (RCA) is one tool commonly used to identify factors contributing to adverse events. Using RCA data from the Veterans Health Administration (VHA), this study characterized adverse events occurring during urologic procedures. The most common causes of adverse events were improperly functioning equipment (e.g., broken scopes or smoking light cords), wrong site surgeries, and retained surgical items.
Brown CE, Marshall AR, Snyder CR, et al. JAMA Netw Open. 2023;6:e2321746.
Minoritized patients face systemic biases that may delay access to safe and appropriate care. In this study, 25 hospitalized Black patients with serious illness described their experiences with racism within the health system, their communication with providers, and medical decision-making within a racialized health system. Study participants reported mistrusting the health system, being silenced by providers about their own knowledge and experiences, and feeling isolated as a result.
Stierman EK, O'Brien BT, Stagg J, et al. Qual Manag Health Care. 2023;32:177-188.
Maternal morbidity and mortality remain a significant problem in U.S. health care. This article describes Texas and Oklahoma’s adoption of a perinatal quality improvement initiative, including the implementation of the Alliance for Innovation of Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units. Findings suggest that adoption of initiative components varies across obstetric units; the majority of units had standardized processes for serious events (obstetric hemorrhage, massive transfusion, severe hypertension) but fewer units offered regular training on effective teamwork and communication for their staff.
Doshi S, Shin S, Lapointe-Shaw L, et al. JAMA Intern Med. 2023;183:924-932.
Missed recognition of early signs of clinical deterioration can result in transfer to the intensive care unit (ICU) or death. This study investigated whether critical illness events (transfer to ICU or death) impacted another patient's critical illness event in the subsequent six-hour period. Results suggest one or more critical illness events increase the odds of additional patient transfers into the ICU, but not of death. The authors present several explanations for this phenomenon.
Gur-Arieh S, Mendlovic S, Rozenblum R, et al. J Patient Saf. 2023;19:362-368.
Failure mode and effect analysis (FMEA) is a common way to identify error risk. In this study, FMEA was used in a psychiatric hospital emergency department (ED) to identify potential failures. FMEA was completed by two groups, ED staff and non-ED staff, to determine if a multi-professional team could be used for the FMEA process. The groups’ ratings were very similar, indicating a multi-professional team can effectively complete an FMEA.
Arredondo Montero J, Bardají Pascual C. Clin Pediatr (Phila). 2023;Epub May 29.
Human factors strategies are increasingly applied in health care to mitigate the impact of human error in medicine. This article discusses the use of checklists to systematize anesthesia and reduce risk in pediatric surgery.
Watterson TL, Steege LM, Mott DA, et al. Jt Comm J Qual Patient Saf. 2023;49:485-493.
Occupational fatigue (e.g., stress, physical fatigue) can have deleterious effects on patients, staff, and health systems. This article describes a conceptual framework to better understand the factors contributing to occupational fatigue and downstream implications (e.g., poor patient safety, employee burnout, lower retention, and higher turnover).
Schattner A. Eur J Intern Med. 2023;115:29-33.
Older patients are particularly vulnerable to harm during hospitalization. This article summarizes potential patient harm that can occur during hospitalization for older adults, including unnecessary testing or procedures, nosocomial infections, medical errors, falls, functional or cognitive decline, and post-discharge adverse events.
Puhl RM. Gastroenterol Clin North Am. 2023;52:417-428.
Implicit biases and stigma can impede the delivery of safe, high-quality healthcare. This article outlines the ways in which stigma create barriers to effective care for patients with obesity (use of stigmatizing language, provider-held negative weight-based attitudes, lack of patient-centered communication, patient avoidance, and/or delay of care). The authors propose several strategies to reduce weight stigma in health care, including stigma-reduction education and training interventions.
No results.

Maxwell A. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2023. Report no. OEI-06-21-00030.

Medical record review is a primary tactic to identify health care actions that contribute to patient harm. This report discusses the review process used in the 2018 report Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm to illustrate a successful review process for use by clinicians and researchers. It is a companion toolkit to the Clinical Guidance for Identifying Harm publication.

Kans J Med. 2023;June 2016:153-171.

The well-being of the healthcare workforce is known to impact care delivery. This article series draws from front-line scenarios to illustrate how a wide range or personal and professional challenges intersect to affect patient safety. Topics covered in the presented cases include work-life integration, gender discrimination and clinical mistakes.

New York, NY: United Nations Population Fund; July 2023.

Black women are vulnerable to unsafe health care. This report examined maternal and reproductive health care for Black women in nine countries across the Americas. The analysis found poor data collection, indifferent policies, and systemic racism and sexism as factors contributing to disparities in care for this patient population.
Newspaper/Magazine Article

Decamp M, Lindvall C. Science. 2023;381(6654):150-152.

Computerized clinical support is vulnerable to bias due to widespread health care inequalities that feed into the systems. This article discusses the need for collective effort to increase equitable application of artificial intelligence through a recognition of latent factors at the clinician, patient, and policy levels that contribute to algorithmic biases.

Washington, DC: VA Office of the Inspector General; June 28, 2023. Report no. 22-02725-132.

Delays in emergency care provision can contribute to patient harm. This analysis examined an instance of cardiopulmonary resuscitation (CPR) delay and the poor response once the emergency was identified at an outpatient clinic. System-level issues flagged include incomplete incident records and follow up. Staff training, emergency notification, CPR process compliance, and debrief results completion were among the recommendations for improvement.

This Month’s WebM&Ms

WebM&M Cases
Sean Flynn, MD and David K. Barnes, MD, FACEP |
A 56-year-old woman presented to the emergency department (ED) with shaking, weakness, poor oral intake and weight loss, constipation for several days, subjective fevers at home, and mild pain in the chest, back and abdomen. An abdominal x-ray confirmed a large amount of stool in the colon with no free air and her blood leukocyte count was 11,500 cells/μL with 31% bands. She received intravenous fluids but without any fecal output while in the ED. She was discharged to home with a diagnosis of constipation, dehydration and failure to thrive and planned follow-up with her primary care provider. Three days later, she was admitted to a second hospital and the surgeon found stercoral colitis and a large perforated “stercoral ulcer” of the proximal sigmoid colon with disseminated fecal and purulent material. Despite aggressive surgical and postoperative care, she expired from sepsis ten days later. The commentary summarizes the diagnosis and management of stercoral colitis and the importance of prompt identification of bandemia, which should trigger further investigation for an underlying infection.
WebM&M Cases
Spotlight Case
Theresa Duong, MD, Noelle Boctor, MD, and James Bourgeois, OD, MD |
This case describes a 65-year-old man with alcohol use disorder who presented to a hospital 36 hours after his last alcoholic drink and was found to be in severe alcohol withdrawal. The patient’s Clinical Institute Withdrawal Assessment (CIWA) score was very high, indicating signs and symptoms of severe alcohol withdrawal. He was treated with symptom-triggered dosing of benzodiazepines utilizing the CIWA protocol and dexmedetomidine continuous infusion. The treating team had planned to wean the infusion; however, the following day, the patient was noted to be obtunded on a high dose of dexmedetomidine. He remained somnolent for two additional days and subsequently developed aspiration pneumonia and Clostridioides difficile colitis, which further prolonged his hospital stay and strained relationships among the patient's family, the nursing staff and medical team. The commentary reviews the medications commonly used to treat alcohol withdrawal and the risks associated with these medications, the use of standardized medication order sets for continuous weight-based infusions within the intensive care unit, and ways to minimize clinician bias in assessing and treating substance use disorders.
WebM&M Cases
Christian Bohringer, MBBS, James Bourgeois, OD, MD, Glen Xiong, MD, and Emily Wei, MD |
A 50-year-old unhoused patient presented to the Emergency Department (ED) for evaluation of abdominal pain, reportedly one day after swallowing multiple sharp objects. Based on the radiologic finding of an open safety pin or paper clip in the distal stomach, he was appropriately scheduled for urgent esophagogastroduodenoscopy and ordered to remain NPO (nothing by mouth) to reduce the risk of aspirating gastric contents. However, the order was not communicated verbally and he was allowed to eat, leading to postponement of the procedure and ultimately to an unsatisfactory conclusion with discharge of the patient against medical advice. This case raises interesting questions about the evaluation and treatment of pica in the ED, the communication of dietary status information, the risks of procedural sedation in a non-fasting patient, and the evaluation of decisional capacity in a patient with recurrent pica.

This Month’s Perspectives

Regina Hoffman
Interview
Regina M. Hoffman, MBA, RN, Cindy Manaoat Van, MHSA, CPPS,Sarah E. Mossburg, RN, PhD |
Perspectives on Safety
Regina M. Hoffman, MBA, RN, Cindy Manaoat Van, MHSA, CPPS, Sarah E. Mossburg, RN, PhD |
This piece focuses on the importance of building the capacity of the workforce and organizations for patient safety using patient safety education.
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