The PSNet Collection

Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples.

US Food and Drug Administration. October 7, 2021.

Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this updated announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.

Leading causes of anesthesia-related liability claims in ambulatory surgery centers.

Ranum D, Beverly A, Shapiro FE, et al. J Patient Saf. 2021;17(7):513-521.

This analysis of medical malpractice claims identified four leading causes of anesthesia-related claims involving ambulatory surgery centers – dental injuries, pain, nerve damage, and death. The authors discuss the role of preoperative risk assessment, use of routine dental and airway assessment, adequate treatment of perioperative pain, and improving communication between patients and providers.

Patient safety and mental health-a growing quality gap in Canada.

Waddell AE, Gratzer D. Can J Psychiatry. 2021:070674372110365.

Safety gaps in mental health care offers a limited view if focused primarily on patient suicide. This commentary calls for Canadian psychiatric professionals to examine the safety of their patients from a system perspective to develop a research and practice improvement strategy.

Health Equity and Maternal Health

October 6, 2021

This piece discusses an expanded view of maternal and infant safety that includes the concept of whole-person care, which addresses the structural and social determinants of maternal health.

In conversation with….Alison Stuebe, MD, MSc and Kristin Tully, PhD

October 6, 2021

Alison Stuebe, MD, MSc, is a professor and Division Director for Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology at the University of North Carolina (UNC) at Chapel Hill and the co-director of the Collaborative for Maternal and Infant Health. Kristin Tully, PhD, is a research assistant professor in the Department of Obstetrics and Gynecology at UNC Chapel Hill and a member of the Collaborative for Maternal and Infant Health.

ISMP List of High-Alert Medications in Community/Ambulatory Healthcare.

Horsham, PA: Institute for Safe Medication Practices; 2021.

This fact sheet provides a list of high-alert medications commonly used in ambulatory care and recommends strategies to reduce risk of errors.

Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations

September 29, 2021

This case describes multiple emergency department (ED) encounters and hospitalizations experienced by a middle-aged woman with sickle cell crisis and a past history of multiple, long admissions related to her sickle cell disease. The multiple encounters highlight the challenges of opioid prescribing for patients with chronic, non-cancer pain.

Achieving Excellence in Cancer Diagnosis.

National Academies of Sciences, Engineering, and Medicine. October 6, 2021. 10:30 AM - 5:30 PM (eastern).

Diagnostic errors remain an ongoing challenge in many medical specialties, including oncology. This workshop will review the evidence base examining challenges in cancer diagnosis, discuss suggestions for improvement in the field, and look toward a safer future for cancer patients.

Open Notes shines light on errors in patient medical records — will the new rule lead to a flood of correction requests?

Clark C. MedPage Today. September 14, 2021.

Patients who have access to their records often find errors that need to be corrected. This story highlights recent US policy changes requiring patient access to their records and explores the impact that requests for changes could have on getting records fixed to ensure accurate information is available to inform future care decisions.

Canadian Patient Safety Week.

Healthcare Excellence Canada

This site provides promotional materials for an annual awareness campaign on patient safety that takes place in the autumn. The 2021 observance, focusing on the importance of essential care partners, will be held October 25th through 29th.

Maternal Safety

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Medicine's Shadowside: Revisiting Clinical Iatrogenesis.

Varley E, Varma S, eds. Anthropol Med. 2021;28(2);141-278.

Implicit biases are rooted in culture and context. This special issue examines a broad range of influences and impacts of medical harm enabled by societal acceptance of inequalities both within medicine and beyond it.

Racial disparities in preventable adverse events attributed to poor care coordination reported in a national study of older US adults.

Pinheiro LC, Reshetnyak E, Safford MM, et al. Med Care. 2021;Epub Aug 14.

Prior research has found that racial/ethnic minorities may be at higher risk for adverse patient safety outcomes. This study evaluated racial disparities in self-reported adverse events based on cross-sectional survey data collected as part of a national, prospective cohort evaluating stroke mortality. Findings show that Black participants were significantly more likely to report a preventable adverse event attributable to poor care coordination (e.g., drug-drug interaction, emergency department visitor, or hospitalization) compared to White participants.

Medical Office Survey on Patient Safety Culture.

Rockville, MD: Agency for Healthcare Research and Quality; October 2020.

This survey collects information from outpatient providers and staff about the culture of patient safety in their medical offices. The survey is intended for offices with at least three providers, but it also can be used as a tool for smaller offices to stimulate discussion about quality and patient safety issues. The survey is accompanied by a set of resources to support its use. The current data submission window launched on September 1 and runs through October 20, 2021.

ASHP guidelines on the safe use of automated dispensing devices.

Cello R, Conley M, Cooley TW, et al. Am J Health Syst Pharm. 2021;Epub 2021 Aug 29.

This document shares goals and objectives to enhance use of automated dispensing devices for pharmacists, other practitioners, and information system professionals.

Association of dose tapering with overdose or mental health crisis among patients prescribed long-term opioids.

Agnoli A, Xing G, Tancredi DJ, et al. JAMA. 2021;326(5):411-419.

Sudden discontinuation of opioids has been linked to increased patient harm. This observational study evaluated the link between tapering and overdose, and mental health crisis among patients who were receiving long-term opioid therapy. Patients who underwent dose tapering had an increased risk of overdose and mental health crisis compared to those who did not undergo dose tapering.

The COVID trap: pediatric diagnostic errors in a pandemic world.

Fatemi Y, Coffin SE. Diagnosis (Berl). 2021;Epub Aug 5.

Using case studies, this commentary describes how availability bias, diagnostic momentum, and premature closure resulted in delayed diagnosis for three pediatric patients first diagnosed with COVID-19. The authors highlight cognitive and systems factors that influenced this diagnostic error.

FDA Safety Communication: update--robotically-assisted surgical devices in mastectomy.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.

This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.

Patient factors and hospital outcomes associated with atypical presentation in hospitalized older adults with COVID-19 during the first surge of the pandemic.

Marziliano A, Burns E, Chauhan L, et al. J Gerontol A Biol Sci Med Sci. 2021;Epub Jul 19.

Many COVID-19 patients present with atypical symptoms, such as delirium, smell and taste dysfunction, or cardiovascular features. Based on inpatient electronic health record data between March 1 and April 20 of 2020, this cohort study examined the frequency of atypical presentation of COVID-19 among older adults. Analyses suggest that atypical presentation was often characterized by functional decline or altered mental status.

Recognizing Unsafe Care: What It Is and How to Report It.

Patient Safety Foundation. August 26, 2021.

This webinar introduced medical error and harm as related concepts to identify unsafe care and enhance response, engagement, and reporting efforts of clinicians, patients and families.

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