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September 28, 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

Hodkinson A, Zhou, A, Johnson J, et al. BMJ. 2022;378:e070442.
Clinician burnout is a significant issue that can impact patient safety. This systematic review and meta-analysis showed physicians with burnout were significantly more dissatisfied with their jobs, were more regretful of their chosen career path, and had higher intention to leave their jobs. The association between burnout and patient satisfaction, patient safety, and professionalism is also discussed.
Richie CD, Castle JT, Davis GA, et al. Angiology. 2022;73:712-715.
Hospital-acquired venous thromboembolism (VTE) continues to be a significant source of preventable patient harm. This study retrospectively examined patients admitted with VTE and found that only 15% received correct risk stratification and appropriate management and treatment. The case review found that patients were commonly incorrectly stratified, received incorrect pharmaceutical treatment, or inadequate application of mechanical prophylaxis (e.g., intermittent compression).
Yuan CT, Dy SM, Yuanhong Lai A, et al. Am J Med Qual. 2022;37:379-387.
Patient safety in ambulatory care settings is receiving increased attention. Based on interviews and focus groups with patients, providers, and staff at ten patient-centered medical homes, this qualitative study explored perceived facilitators and barriers to improving safety in ambulatory care. Participants identified several safety issues, including communication failures and challenges with medication reconciliation, and noted the importance of health information systems and dedicated resources to advance patient safety. Patients also emphasized the importance of engagement in developing safety solutions. A recent PSNet perspective discusses patient safety challenges in ambulatory care, particularly during the COVID-19 pandemic.
Passwater M, Huggins YM, Delvo Favre ED, et al. Am J Clin Pathol. 2022;158:212-215.
Wrong blood in tube (WBIT) errors are rare but can lead to complications. One hospital implemented a quality improvement project to reduce WBIT errors with electronic patient identification, manual independent dual verification, and staff education. WBIT errors were significantly reduced and sustained over six years.
Yuan CT, Dy SM, Yuanhong Lai A, et al. Am J Med Qual. 2022;37:379-387.
Patient safety in ambulatory care settings is receiving increased attention. Based on interviews and focus groups with patients, providers, and staff at ten patient-centered medical homes, this qualitative study explored perceived facilitators and barriers to improving safety in ambulatory care. Participants identified several safety issues, including communication failures and challenges with medication reconciliation, and noted the importance of health information systems and dedicated resources to advance patient safety. Patients also emphasized the importance of engagement in developing safety solutions. A recent PSNet perspective discusses patient safety challenges in ambulatory care, particularly during the COVID-19 pandemic.
Westbrook JI, McMullan R, Urwin R, et al. Intern Med J. 2022;Epub Aug 24.
The COVID-19 pandemic dramatically impacted team functioning in healthcare settings. This survey of nearly 1,600 clinical and non-clinical staff at five Australian hospitals did not identify any perceived increases in unprofessional behaviors during the pandemic and 44% of respondents cited improvements in teamwork.
Suneja M, Beekmann SE, Dhaliwal G, et al. Diagnosis (Berl). 2022;9:332-339.
Delayed diagnosis of infectious diseases can lead to serious patient harm. This survey of over 500 infectious disease clinicians revealed that diagnostic delay often involved diagnoses of infective endocarditis and epidural abscesses. Respondents identified several factors contributing to diagnostic delays including usual clinical presentations and the timing of infectious disease consultations.
Bagnasco A, Rossi S, Dasso N, et al. J Patient Saf. 2022;18:e903-e911.
Care left undone (also called missed care, unfinished care, and implicitly rationed care) is associated with lower perception of safety culture and increased adverse events. In this study, more than 2,200 pediatric nurses were asked about care tasks left undone in their most recent shift and a variety of environmental factors (e.g., perception of their work environment, risk of burnout). The most frequently omitted task was comfort/talk with patients, and the least frequently omitted task was pain management.
FitzGerald C, Mumenthaler C, Berner D, et al. BMC Med Ethics. 2022;23:86.
Patients with obesity and mental illness face both explicit and implicit bias that negatively impact their healthcare. This study of psychiatric and general internal medicine physicians analyzed implicit and explicit bias towards patients with mental illness and/or obesity. Results varied by specialty, physician age, gender, and experience level.
Montminy SL. J Healthc Risk Manag. 2022;Epub Aug 22.
Organizational leaders play a critical role in supporting a strong patient safety culture. In this study, patient safety leaders were interviewed to determine leadership characteristics and attitudes associated with creating and maintaining a robust safety culture. Results reveal several behaviors (e.g., exhibiting patient safety behavior), beliefs (e.g., fair and equitable measures of accountability), and characteristics (e.g., building trust and connections) that leaders need to support a successful culture of safety.
Richie CD, Castle JT, Davis GA, et al. Angiology. 2022;73:712-715.
Hospital-acquired venous thromboembolism (VTE) continues to be a significant source of preventable patient harm. This study retrospectively examined patients admitted with VTE and found that only 15% received correct risk stratification and appropriate management and treatment. The case review found that patients were commonly incorrectly stratified, received incorrect pharmaceutical treatment, or inadequate application of mechanical prophylaxis (e.g., intermittent compression).
Zabinski Z, Black BS. J Health Econ. 2022;84:102638.
Tort reform and changes in medical malpractice liability can impact patient safety. This longitudinal analysis found that caps on noneconomic damages in medical malpractice lawsuits were associated with higher rates of preventable adverse events in hospitals.
Lin JS, Olutoye OO, Samora JB. J Pediatr Surg. 2022;Epub Jul 6.
Clinicians involved in adverse events may experience feelings of guilt, shame, and inadequacy; this is referred to as “second victim” phenomenon. In this study of pediatric surgeons and surgical trainees, 84% experienced a poor patient outcome. Responses to the adverse event varied by level of experience (e.g., resident, attending), gender, and age.
Rogers JE, Hilgers TR, Keebler JR, et al. Jt Comm J Qual Patient Saf. 2022;Epub Jun 23.
Patient safety investigations hinge on the expertise and experiences of the investigator. This commentary discusses the ways in which cognitive biases can impact patient safety investigations and identifies potential mitigation strategies to improve decision-making processes.
Quesenberry M. Patient Safety. 2022;4:6-9.
Medical devices intended to improve patient safety can unintentionally lead to patient harm. This patient safety alert draws attention to the risk of injury when hospital wheelchairs are used by staff, patients, or visitors who may not have training in safe use. Understanding the proper use of the wheelchair, particularly folding wheelchairs, is crucial to ensuring safety.
Hodkinson A, Zhou, A, Johnson J, et al. BMJ. 2022;378:e070442.
Clinician burnout is a significant issue that can impact patient safety. This systematic review and meta-analysis showed physicians with burnout were significantly more dissatisfied with their jobs, were more regretful of their chosen career path, and had higher intention to leave their jobs. The association between burnout and patient satisfaction, patient safety, and professionalism is also discussed.
Lipori JP, Tu E, Shireman TI, et al. J Am Med Dir Assoc. 2022;23:1589.e1-1589.e10.
Despite evidence of associated adverse events, older adults in nursing homes are frequently prescribed potentially inappropriate medications (PIM). This review sought to identify facility and prescriber characteristics associated with PIM prescribing. Anti-psychotic medications were the focus of more than half of included studies, and were associated with low registered nurse staffing, for-profit facility status, and younger men. No study investigated prescriber characteristics.
Schilling S, Armaou M, Morrison Z, et al. PLoS ONE. 2022;17:e0272942.
Effective teamwork is critical in acute and intensive care settings. This systematic review of reviews and thematic analysis identified four key factors that frame the evidence on interprofessional teams in acute and intensive care settings – (1) team internal procedures and dynamics, such as cohesion, organizational culture, and leadership influence; (2) communicative processes; (3) organizational and team-extrinsic influences, such as team composition, hierarchy, and interprofessional dynamics, and; (4) team outcomes, including both patient and staff outcomes.

NAM’s Action Collaborative on Clinician Well-Being and Resilience. Washington DC, American Association of Medical Colleges or virtual; October 3, 2022, 10:00 AM – 12:00 PM (eastern).

Concerted effort has been undertaken to understand the impact of clinician burnout on patient safety. This webinar will discuss the culmination of a six-year effort to design a national multidisciplinary guidance to address system issues that affect the wellbeing of clinicians.

de Bienassis K, Esmail L, Lopert R, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2022. OECD Health Working Papers, No. 147.

The global effect of harm associated with preventable drug errors is substantial. This report discusses the human and financial impact of medication errors in a variety of countries, prescribing process improvement, established efforts to enhance medicine use safety, and avenues for national medication safety achievement.

Rockville, MD: Agency for Healthcare Research and Quality; September 2022. AHRQ Publication No. 22-0026-3-EF.

Correct consideration of the likelihood that a patient may have a potential disease guides each level of diagnostic decision making; misjudgments can be fatal. This issue brief introduces an information-focused framework to examine how clinicians determine probability and discusses educational avenues for enhancing those skills. The publication is part of a report series on diagnostic safety.

Millenson M. Forbes. September 16, 2022.

Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm was noted in the case discussed, the actions by the patient’s family to initiate an examination of the incident were rebuffed, patient disrespect was demonstrated, a near miss incident report was absent, and data omissions took place. The piece discusses how these detractors from safety were all present at the hospital involved.

This Month’s WebM&Ms

WebMandM Cases
Carla S. Martin, MSN, RN, CIC, CNL, NEA-BC, FACHE, Shannon K. Reese, BSN, RN, VABC, and Margaret Brown-McManus, MSN, RN, CNL |
This case describes a 20-year-old woman was diagnosed with a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding a  peripherally inserted central catheter (PICC) line (type, gauge, and length of time the PICC had been in place were not noted). The patient was discharged home but was not given any supplies for cleaning the PICC line, education regarding the signs of PICC line infection, or referral to home health services. During follow-up several days after discharge, the patient’s primary care provider noted that the PICC dressing was due to be changed and needed to be flushed, but the outpatient setting lacked the necessary supplies. An urgent referral to home health was placed, but the agency would be unable to attend to the patient for several days. The primary care provider changed the dressing, and the patient was referred to the emergency department for assessment. The commentary summarizes the risks of PICC lines, the role of infection prevention practices during the insertion and care of PICC lines, and the importance of patient education and skill assessment prior to discharge home with a PICC line.
WebMandM 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.
WebMandM Cases
Commentary by Jennifer Rosenthal, MD, MAS and Michelle Hamline, MD, PhD, MAS |
A 2-year-old girl presented to her pediatrician with a cough, runny nose, low grade fever and fatigue; a nasal swab for SARS-CoV-2 and influenza was negative and lung sounds were clear. The patient developed a fever and labored breathing and was taken to the Emergency Department (ED) before being admitted to the hospital. She developed respiratory distress and clinically worsened over time until she developed respiratory failure requiring air transportation to the pediatric intensive care unit at a children’s hospital. She was ultimately diagnosed with adenovirus after developing conjunctivitis and bronchiolitis. After 3 days of continuous monitoring and treatment in the PICU, the patient was alert, responsive, and hungry. She was taken off supplemental oxygen after about 24 more hours, transferred to a regular pediatric bed, and then discharged to outpatient follow-up care. The commentary addresses patient safety risks associated with pediatric interfacility transfers and strategies to mitigate preventable harms due to poor provider-provider communication, provider-family communication, and family engagement.

This Month’s Perspectives

Freya Spielberg
Perspective
Freya Spielberg MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social enterprise dedicated to improving the health of Individuals living in low-income housing in Washington, DC. Previously, as an Associate Professor at George Washington University, and at the University of Texas Dell Medical School, and School of Public Health, she developed a curriculum in Community Oriented Quality Improvement, to train the next generation of healthcare providers how to integrate population health into primary care to achieve the quintuple aim of better health outcomes, better patient experience, better provider experience, lower health care costs, and decreased health disparities. We spoke with her about her ongoing work in low-income communities to improve access to primary care and its impact on patient safety.
Jack Westfall
Perspective
Jack Westfall, MD MPH, is a retired professor from the University of Colorado School of Medicine and Former Director of the Robert Graham Center. We spoke with him about the role of primary care in the health and well-being of individuals, the hallmarks of high quality primary care and opportunities of primary care providers to enhance or promote patient safety.
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