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January 19, 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

Eiding H, Røise O, Kongsgaard UE. J Patient Saf. 2022;18(1):e315-e319.
Reporting patient safety incidents is essential to improving patient safety. This study compared the number of self-reported (to the study team) safety incidents during interhospital transport and the number of incidents submitted to the hospital’s reporting system. Nearly half of all patient transports had at least one self-reported incident; however, only 1% of incidents were reported to the hospital’s electronic reporting system.
Vaughan CP, Hwang U, Vandenberg AE, et al. BMJ Open Qual. 2021;10(4):e001369.
Prescribing potentially inappropriate medications (such as antihistamines, benzodiazepines, and muscle relaxants) can lead to adverse health outcomes. The Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIPPED) program is a multicomponent intervention intended to reduce potentially inappropriate prescribing among older adults who are discharged from the emergency department. Twelve months after implementation at three academic health systems, the EQUIPPED program significantly reduced overall potentially inappropriate prescribing at one site; the proportion of benzodiazepine prescriptions decreased across all sites.
Viscardi MK, French R, Brom H, et al. Policy Polit Nurs Pract. 2022;Epub Jan 6.
Health care work environments can influence safety culture and teamwork. This study used multiyear survey data from registered nurses in 503 hospitals across four states to explore the association between nurse work environment and healthcare quality, patient safety, and patient outcomes. Findings indicate that nurse work environment (such as nurse participation in hospital affairs, nurse manager capability, leadership support, and nurse-physician relationships) is an important factor to improving the experiences of patients and nurses, especially those in hospitals caring for economically disadvantaged patients.
Hammond Mobilio M, Paradis E, Moulton C-A. Am J Surg. 2021;Epub Nov 24.
Surgical safety checklists (SSC) have been adopted around the world, but reported compliance rates and use in practice vary widely. This study in one Canadian hospital showed the SSC was used in 82% of Briefings, 76% of Time-Outs, and 22% of Debriefings. Gaps between policy and practice were identified and implications for policy makers, administrators, frontline clinicians, and researchers are discussed.
Gampetro PJ, Segvich JP, Hughes AM, et al. J Pediatr Nurs. 2021;63:20-27.
Communicating and reporting patient safety incidents relies on a robust safety culture wherein health care providers feel supported, not blamed, for errors. Using pediatric registered nurses’ responses from the 2016 and 2018 Hospital Survey on Patient Culture, researchers explored (1) associations between the communication of RNs within their teams and the frequency that they reported safety events; (2) associations between RNs’ communication within their health care teams and their perceptions of safety within the hospital unit; and (3) whether RNs’ communication had improved from 2016 to 2018.
Viscardi MK, French R, Brom H, et al. Policy Polit Nurs Pract. 2022;Epub Jan 6.
Health care work environments can influence safety culture and teamwork. This study used multiyear survey data from registered nurses in 503 hospitals across four states to explore the association between nurse work environment and healthcare quality, patient safety, and patient outcomes. Findings indicate that nurse work environment (such as nurse participation in hospital affairs, nurse manager capability, leadership support, and nurse-physician relationships) is an important factor to improving the experiences of patients and nurses, especially those in hospitals caring for economically disadvantaged patients.
Höcherl A, Lüttel D, Schütze D, et al. J Patient Saf. 2022;18(1):e85-e91.
Critical incident reporting systems (CIRS) are used to improve learning and patient safety. The aim of this study was to support future implementation of CIRS in primary care by discussing types of incidents that should be reported; who can report incidents (e.g., nurses, physicians, patients); whether reporting is mandatory or voluntary or both depending on incident severity; local versus central analysis; barriers and methods to overcome them; and motivation for reporting.
Vaughan CP, Hwang U, Vandenberg AE, et al. BMJ Open Qual. 2021;10(4):e001369.
Prescribing potentially inappropriate medications (such as antihistamines, benzodiazepines, and muscle relaxants) can lead to adverse health outcomes. The Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIPPED) program is a multicomponent intervention intended to reduce potentially inappropriate prescribing among older adults who are discharged from the emergency department. Twelve months after implementation at three academic health systems, the EQUIPPED program significantly reduced overall potentially inappropriate prescribing at one site; the proportion of benzodiazepine prescriptions decreased across all sites.
Sosa T, Mayer B, Chakkalakkal B, et al. Hosp Pediatr. 2022;12(1):37-46.
Many medications and medical devices can result in preventable harm in pediatric patients. This article describes one hospital’s efforts to implement explicit, structured processes and huddles to increase situational awareness regarding high-risk therapies among the care team and family members. After implementation, the percentage of electronic health record (EHR) alerts correctly describing high-risk therapies increased from 11% to 96%.
Eiding H, Røise O, Kongsgaard UE. J Patient Saf. 2022;18(1):e315-e319.
Reporting patient safety incidents is essential to improving patient safety. This study compared the number of self-reported (to the study team) safety incidents during interhospital transport and the number of incidents submitted to the hospital’s reporting system. Nearly half of all patient transports had at least one self-reported incident; however, only 1% of incidents were reported to the hospital’s electronic reporting system.
Lyndon A, Simpson KR, Spetz J, et al. Appl Nurs Res. 2022;63:151516.
Missed nursing care appears to be associated with higher rates of adverse events. More than 3,600 registered nurses (RNs) were surveyed about missed care during labor and birth in the United States. Three aspects of nursing care were reported missing by respondents: thorough review of prenatal records, missed timely documentation of maternal-fetal assessments, and failure to monitor input and output.
Marr R, Goyal A, Quinn M, et al. BMC Health Serv Res. 2021;21(1):1330.
Many hospitals are implementing programs to support clinicians involved in adverse events (‘second victims’). Researchers interviewed 12 representatives of second victim programs in the United States about the experiences of their programs. The article discusses representative feedback regarding the importance of identifying a need for second victim programs and services, perceived challenges to program success, structural changes after program implementation, and insights for success.   
Dixon-Woods M, Aveling EL, Campbell A, et al. J Health Serv Res Policy. 2022;Epub Jan 3.
A key aspect of patient safety culture is the perception that all team members should speak up about safety concerns. In this study of 165 frontline and senior leader participants, deciding to report a safety event (referred to as a “voiceable concern”) is influenced by four factors: certainty that something is wrong and is an occasion for voice; system versus conduct concerns, forgivability, and normalization. Organizational culture and context effect whether an incident is considered a voiceable concern.

Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J. 2021;114(6):4-6. doi: 

Retained surgical items (RSI) are a never event, yet they continue to happen. This commentary summarizes recent changes to an existing guidance that defines a range of retained devices or products to coalesce with industry terminology. The author shares steps to reduce the potential for RSI retention. A related webinar will be held February 2, 2022.
Saliba R, Karam-Sarkis D, Zahar J-R, et al. J Hosp Infect. 2022;119:54-63.
Patient isolation for infection prevention and control may result in unintended consequences. This systematic review examined adverse physical and psychosocial events associated with patient isolation. A meta-analysis of seven observational studies showed no adverse events related to clinical care or patient experience with isolation.
FitzGerald C, Hurst S. BMC Med Ethics. 2017;18(1):19.
Healthcare provider implicit bias can lead to inequitable care delivery and poor patient outcomes. This review identified 42 articles about healthcare professional implicit biases, including gender, race, ethnicity, and age. Biases were detected in provider attitudes, treatment decisions, and diagnosis.
Malahias M-A, Antoniadou T, Jang SJ, et al. J Am Acad Orthop Surg. 2021;29(24):e1387-e1395.
Previous research has raised concerns about safety risks associated with overlapping surgery, defined as two procedures performed concurrently, but where critical surgical portions of each procedure occur at different times. Based on a meta-analysis of six articles, the authors of this systematic review found that rates of surgical complications readmissions were similar among overlapping and nonoverlapping surgery in patients undergoing total joint arthroscopy.
Mekonnen AB, Redley B, Courten B, et al. Br J Clin Pharmacol. 2021;87(11):4150-4172.
Potentially inappropriate prescribing in older adults can result in medication-related harm. This systematic review of 63 studies found that potentially inappropriate prescribing was significantly associated with several system-related and health-related outcomes for older adults, including mortality, readmissions, adverse drug events, and functional decline.

Bryant A. UpToDate. September 13, 2021.

Implicit bias is progressively being discussed as a detractor to safe health care by fostering racial and ethnic inequities. This review examines the history of health inequities at the patient, provider, health care system, and cultural levels in obstetric and gynecologic care. It shares actions documented in the evidence base for application in health care to reduce the impact of implicit bias, with an eye toward maternal care
Noor Arzahan IS, Ismail Z, Yasin SM. Safety Sci. 2022;147:105624.
A culture of safety is a key component to successful patient safety initiatives. This systematic review explored the relationship between safety culture and safety climate dimensions and safety performance measures. The most common dimensions used to assess this relationship were the involvement of leadership, safety resources, risk management and communication, safety rules and procedures, and involvement of healthcare workers.

Healthcare Excellence Canada. January 27, 2022, 12:00-1:00 PM (eastern).

Worker safety has emerged as a foundational component of a safe care environment. This webinar will discuss how organizational culture can contribute to or mitigate workplace factors that encourage error-prone conditions such as staff stress or burnout.

Washington, DC: United States Government Accountability Office; November 30, 2021. Publication GAO-22-105142.

Patient complaints have the potential to be used for care improvement as they surface problems in health facilities. This report examined complaint response processes in Veterans Affairs nursing homes and found them lacking. Five recommendations submitted to drive improvement underscore the value of adherence to policy and the transfer of complaint experiences to leadership.

Patient Safety Movement Foundation.

Inspired by efforts to learn from errors that resulted in the death of one young man, this award program recognizes health profession students that lead activities to reduce preventable health care harm. The application deadline is January 28, 2022.

This Month’s WebM&Ms

WebM&M Cases
Jane L. Erb, MD, Sejal B. Shah, MD and Gordon D. Schiff, MD |
An 18-year-old man with a history of untreated depression and suicide attempts (but no history of psychiatric hospitalizations) was seen in the ED for suicidal ideation after recent gun purchase. Due to suicidal ideation, he was placed on safety hold and a psychiatric consultation was requested. The psychiatry team recommended discharge with outpatient therapy; he was discharged with outpatient resources, the crisis hotline phone number, and strict return precautions. After two encounters with his primary care provider and another visit to the ED for suicidal ideation, the patient was found with a loaded gun in a hotel room. He was taken to the ED for a third time, where has was evaluated and involuntarily admitted to an inpatient psychiatric hospital for five weeks.  He was ultimately discharged with a diagnosis of “Bipolar 1 – moderate-severe with mixed features.” The commentary discusses the challenges of screening for suicide risk and the importance of continuity of care for patients at risk of self-harm and suicide.
WebM&M Cases
Candice Sauder, MD, MS, MEd, FACS and Kara T Kleber, MD, MA |
A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several different providers (pre-operative nurse, resident physician, attending physician, and anethesiology team) to help prepare her for the procedure. In the OR, the surgical team performed two separate time-outs while the patient was being prepped, placed under general anesthesia, and draped. After the attending physician began operating, she realized that no radiotracer dye had been injected for the SNLB – a key process step that was supposed to have occurred prior to the surgery. The nuclear medicine team never saw the patient preoperatively, and none of the staff members or teams realized this until the patient was under general anesthesia with an open incision. The commentary discusses how pre-operative checklist protocols can help multidisciplinary teams avoid communication errors and reduce opportunities for adverse events.

This Month’s Perspectives

Interview
Patient Safety Organizations (PSOs) are organizations dedicated to improving patient safety and healthcare quality that serve to collect and analyze data voluntarily reported by healthcare providers to promote learning. Federal confidentiality and privilege protections apply to certain information (defined as “patient safety work product”) developed when a healthcare provider works with a federally listed PSO under the Patient Safety and Quality Improvement Act of 2005 and its implementing regulation. AHRQ is responsible for the administration and enforcement of the PSO listing process. Based on their presentations at an AHRQ annual meeting, we spoke with representatives from two PSOs, Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO about how the unique circumstances surrounding care during the COVID-19 pandemic impacted patient safety risks in both COVID-19 and non-COVID-19 patients.
Perspective
This piece discusses patient safety challenges that arose as a result of the unique care circumstances surrounding the COVID-19 pandemic, particularly at the height of the pandemic in 2020. 
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