National Survey of Patient Safety Experiences in Hospital Medicine During the COVID-19 Pandemic.

BACKGROUND: During the COVID-19 pandemic, hospitals were caring for increasing numbers of patients with a novel and highly contagious respiratory illness, forcing adaptations in care delivery. The objective of this study was to understand the impact of these adaptations on patient safety in hospital medicine. METHODS: The authors conducted a nationwide survey to understand patient safety challenges experienced by hospital medicine clinicians during the COVID-19 pandemic. The survey was distributed to members of the Society of Hospital Medicine via an e-mail listserv. It consisted of closed- and open-ended questions to elicit respondents' experience in five domains: error reporting and communication, staffing, equipment, personal protective equipment (PPE) and isolation practices, and infrastructure. Quantitative questions were reported as counts and percentages; qualitative responses were coded and analyzed for relevant themes. RESULTS: Of 196 total responses, 167 respondents (85.2%) were attending physicians and 85 (43.8%) practiced at teaching hospitals. Safety concerns commonly identified included nursing shortages (71.0%), limiting patient interactions to conserve PPE (61.9%), and feeling that one was practicing in a more hazardous environment (61.4%). In free-text responses, clinicians described poor outcomes and patient decompensation due to provider and equipment shortages, as well as communication lapses and diagnostic errors resulting from decreased patient contact and the need to follow isolation protocols. CONCLUSION: Efforts made to accommodate shortages in staff and equipment, adapt to limited PPE, and enforce isolation policies had unintended consequences that affected patient safety and created a more hazardous environment characterized by less efficient care, respiratory decompensations, diagnostic errors, and poor communication with patients.

Simultaneous Development of Acute Acquired Concomitant Esotropia in Two Siblings during the COVID-19 Pandemic: A Case Report.

Aim: To report a case of two siblings who near-simultaneously developed a large angle concomitant esotropia during the COVID-19 pandemic, and to describe their treatment and outcomes. Method: A 5-year-old boy and his 11-year-old sister were presented to the hospital eye service in early 2021, having both developed acute-onset large angle esotropia within three months of each other. Neither had any significant past medical, ophthalmic, or family history. The siblings lived in the same household, and both experienced lifestyle changes as a result of the UK lockdown in response to COVID-19. Results: Each sibling was treated with right medial rectus recession (5.5 mm) and right lateral rectus resection (7 mm), and at a three-month follow-up, both were minimally esophoric with restored binocularity. Conclusion: The unusual and abrupt changes in lifestyle imposed by the COVID-19 pandemic highlight the likelihood of an environmental aetiology for some forms of esotropia and raise the possibility that extended screen time may be a contributory factor.

Examining medication ordering errors using AHRQ network of patient safety databases.

BACKGROUND: Studies examining the effects of computerized order entry (CPOE) on medication ordering errors demonstrate that CPOE does not consistently prevent these errors as intended. We used the Agency for Healthcare Research and Quality (AHRQ) Network of Patient Safety Databases (NPSD) to investigate the frequency and degree of harm of reported events that occurred at the ordering stage, characterized by error type. MATERIALS AND METHODS: This was a retrospective observational study of safety events reported by healthcare systems in participating patient safety organizations from 6/2010 through 12/2020. All medication and other substance ordering errors reported to NPSD via common format v1.2 between 6/2010 through 12/2020 were analyzed. We aggregated and categorized the frequency of reported medication ordering errors by error type, degree of harm, and demographic characteristics. RESULTS: A total of 12 830 errors were reported during the study period. Incorrect dose accounted for 3812 errors (29.7%), followed by incorrect medication 2086 (16.3%), and incorrect duration 765 (6.0%). Of 5282 events that reached the patient and had a known level of severity, 12 resulted in death, 4 resulted in severe harm, 45 resulted in moderate harm, 341 resulted in mild harm, and 4880 resulted in no harm. CONCLUSION: Incorrect dose and incorrect drug orders were the most commonly reported and harmful types of medication ordering errors. Future studies should aim to develop and test interventions focused on CPOE to prevent medication ordering errors, prioritizing wrong-dose and wrong-drug errors.

Critical Care Clinicians' Experiences of Patient Safety During the COVID-19 Pandemic.

OBJECTIVE: It is unknown how hospital- and systems-level factors have impacted patient safety in the intensive care unit (ICU) during the COVID-19 pandemic. We sought to understand how the pandemic has exacerbated preexisting patient safety issues and created novel patient safety challenges in ICUs in the United States. METHODS: We performed a national, multi-institutional, mixed-methods survey of critical care clinicians to elicit experiences related to patient safety during the pandemic. The survey was disseminated via email through the Society of Critical Care Medicine listserv. Data were reported as valid percentages, compared by COVID caseload and peak of the pandemic; free-text responses were analyzed and coded for themes. RESULTS: We received 335 survey responses. On general patient safety, 61% felt that conditions were more hazardous when compared with the prepandemic period. Those who took care of mostly COVID-19 patients were more likely to perceive that care was more hazardous (odds ratio, 4.89; 95% CI, 2.49-9.59) compared with those who took care of mostly non-COVID-19 or no COVID-19 patients. In free-text responses, providers identified patient safety risks related to pandemic adaptations, such as ventilator-related lung injury, medication and diagnostic errors, oversedation, oxygen device removal, and falls. CONCLUSIONS: Increased COVID-19 case burden was significantly associated with perceptions of a less safe patient care environment by frontline ICU clinicians. Results of the qualitative analysis identified specific patient safety hazards in ICUs across the United States as downstream consequences of hospital and provider strain during periods of the COVID-19 pandemic.

Outcomes After Injection-Based Therapy: A Pain Outcomes Questionnaire for Veterans Univariate Analysis.

Background: The Pain Outcomes Questionnaire-For Veterans (POQ-VA) was developed within the Veterans Health Administration (VHA) as a brief but psychometrically sound pain outcomes instrument that assesses key domains. In routine clinical practice, it is valid and reliable for evaluating effectiveness of treatment of chronic noncancer pain in veterans. We hypothesized that POQ-VA scores would improve across multiple domains in the veteran population following injection-based interventional treatment for chronic pain. Methods: We aggregated all available POQ-VA reports from veterans who underwent ≥ 1 interventional pain procedures between April 1, 2009 and April 1, 2019. Patients were included who had pre- and posttreatment POQ-VA results separated by ≤ 6 months (N = 112). A paired-samples t test was used to compare means, standard deviations, and ranges for each POQ-VA domain. Individual question responses were analyzed using a nonparametric Wilcoxon matched-pairs signed-rank test. Results: All POQ-VA domains showed a statistically significant decrease posttreatment (P ≤ .03). Directionally, the responses to 17 of 20 individual POQ-VA questions reflect a small but statistically significant positive treatment response (P < .04). Conclusions: Most veterans undergoing injection therapy for chronic pain had statistically significant improvements in POQ-VA measures within a 6-month period. To conduct more rigorous, multivariate studies, continued and widespread use of the POQ-VA instrument is warranted.

The establishment of a 3D anatomical coordinate system for defining vaginal axis and spatial position.

BACKGROUND AND OBJECTIVE: Pelvic organ prolapse (POP), the herniation of the pelvic organs toward the vaginal opening, is a common pelvic floor disorder (PFD) whose etiology is poorly understood. Traditional methods for evaluating POP are often constrained to external vaginal examination, limited to 2D, or have poor reproducibility. We propose a reliable 3D anatomic coordinate system for standardized 3D assessment of pelvic anatomy using magnetic resonance imaging (MRI). METHODS: The novel 3D anatomic reference system is based on six bony landmarks of the pelvis manually identified in MRI: the ischial spines and the superior and inferior pubic points of the left and right pubic symphysis. The origin of this system is defined as the midpoint of the ischial spines. The reproducibility and applicability of the pelvic coordinate system were evaluated by (1) implementing it in a new method to quantify vaginal position and axis (angulation) in 3D space from MRI segmentations of the vagina and (2) computing the intraclass correlation (ICC) on coordinate system and vaginal measures. The MRI analysis was performed by four non-medically trained observers on five pelvic MRI datasets on approximately five separate occasions. RESULTS: Overall, all bony landmarks had excellent intra-observer reliability and inter-observer reliability (ICC>0.90); intra-observer reliability was moderate-to-good among the vaginal position parameters (0.5

The effect of systemic lidocaine on post-operative opioid consumption in ambulatory surgical patients: a meta-analysis of randomized controlled trials.

BACKGROUND: Ambulatory surgical procedures continue to grow in relevance to perioperative medicine. Clinical studies have examined the use of systemic lidocaine as a component of multimodal analgesia in various surgeries with mixed results. A quantitative review of the opioid-sparing effects of systemic lidocaine in ambulatory surgery has not been investigated. The primary objective of this study was to systematically review the effectiveness of systemic lidocaine on postoperative analgesic outcomes in patients undergoing ambulatory surgery. METHODS: We performed a quantitative systematic review of randomized controlled trials in electronic databases (Cochrane Library, Embase, PubMed, and Google Scholar) from their inception through February 2019. Included trials investigated the effects of intraoperative systemic lidocaine on postoperative analgesic outcomes, time to hospital discharge, and adverse events. Methodological quality was evaluated using Cochrane Collaboration's tool and the level of evidence was assessed using GRADE criteria. Data was combined in a meta-analysis using random-effects models. RESULTS: Five trials evaluating 297 patients were included in the analysis. The pooled effect of systemic lidocaine on postoperative opioid consumption at post-anesthesia care unit revealed a significant effect, weighted mean difference (95% CI) of - 4.23 (- 7.3 to 1.2, P = 0.007), and, at 24 h, weighted mean difference (95% CI) of - 1.91 (- 3.80 to - 0.03, P = 0.04) mg intravenous morphine equivalents. Postoperative pain control during both time intervals, postoperative nausea and vomiting reported at post anesthesia care unit, and time to hospital discharge were not different between groups. The incidence rate of self-limiting adverse events of the included studies is 0.007 (2/297). CONCLUSION: Our results suggest that intraoperative systemic lidocaine as treatment for postoperative pain has a moderate opioid-sparing effect in post anesthesia care unit with limited effect at 24 h after ambulatory surgery. Moreover, the opioid-sparing effect did not impact the analgesia or the presence of nausea and vomiting immediately or 24 h after surgery. Clinical trials with larger sample sizes are necessary to further confirm the short-term analgesic benefit of systemic lidocaine following ambulatory surgery. TRIAL REGISTRATION: PROSPERO ( CRD42019142229 ).

Meta-Analysis of the Surgical and Rehabilitative Outcomes of Hip Arthroscopy in Athletes With Femoroacetabular Impingement.

OBJECTIVES: Femoroacetabular impingement (FAI) poses a threat to athletes' capacity to compete. This review aims to estimate the rate of return to sport after hip arthroscopy for treatment of FAI as well as identify factors that may affect athletes' outcomes. DESIGN: Meta-analysis. METHODS: Four databases (EMBASE, PubMed, Web of Science, and Cochrane) were searched in July 2015 by 2 reviewers. Studies were required to include athletes who were treated with hip arthroscopy for symptomatic FAI and also report return to sport as an outcome. A validated tool was used for quality assessment and level of agreement between raters was calculated. A meta-analysis for proportions returning to sport was performed on the available data using MedCalc software. Additional outcomes were descriptively analyzed. RESULTS: A total of 15 case series involving 823 patients were included in the review, with moderate to high methodological quality. 88.3% [95% confidence interval (CI), 83.4%-92.4%] of athletes returned to sport after arthroscopy and 85.3% (95% CI, 77.6%-91.6%) returned to preinjury level. All outcome measures used reported measurable improvements. Complication rates were low. CONCLUSIONS: The majority of athletes return to sport after hip arthroscopy for symptomatic FAI. Severity of intraarticular damage and degree of degenerative changes affect ability to return to sport. Additional validated outcome measures should be used together with return to sport. Future studies should be prospective with longer-term follow-up to provide a higher level of evidence for outcomes.

Pectoral nerve blocks and postoperative pain outcomes after mastectomy: a meta-analysis of randomized controlled trials.

BACKGROUND AND OBJECTIVES: Several studies have evaluated the effect of pectoral nerve blocks to improve postoperative analgesia following breast cancer surgery resulting in contradictory findings. The aim of this study was to examine the effect of Pecs blocks on postoperative analgesia in women following mastectomies. METHODS: We performed a quantitative systematic review in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Articles of randomized controlled trials that compared Pecs block (types I and II) to a control group in patients undergoing mastectomy were included. The primary outcome was total opioid consumption 24 hours after surgery. Secondary outcomes included pain scores and side effects. Meta-analysis was performed using the random effect model. RESULTS: 7 randomized controlled trials with 458 patients were included in the analysis. The effect of pectoral nerve blocks on postoperative opioid consumption compared with control revealed a significant effect, weighted mean difference (WMD) (95% CI) of --4.99 (-7.90 to -2.08) mg intravenous morphine equivalents (p=0.001). In addition, postoperative pain compared with control was reduced at 6 hours after surgery: WMD (95% CI) of -0.72 (-1.37 to -0.07), p=0.03, and at 24 hours after surgery: WMD (95% CI) of -0.91 (-1.81 to -0.02), p=0.04. DISCUSSION: This quantitative analysis of randomized controlled trials demonstrates that the Pecs block is effective for reducing postoperative opioid consumption and pain in patients undergoing mastectomy. The Pecs block should be considered as an effective strategy to improve analgesic outcomes in patients undergoing mastectomies for breast cancer treatment.

Development of best practice recommendations for the safe use of pulmonary hypertension pharmacotherapies using a modified Delphi method.

PURPOSE: The Delphi method was used to develop best practice recommendations (BPR) for safe use of pulmonary hypertension (PH) pharmacotherapies and to describe the pharmacist's role in provision of care. METHODS: A core group reviewed PH medication-safety literature and developed initial BPR. Pharmacists practicing at PH-accredited Centers of Comprehensive Care who met defined PH expert criteria were invited to participate on an expert panel. In round 1 of a 4-round Delphi process, expert input was provided on the BPR. Feedback was incorporated into BPR for the next round. Round 2 proceeded in identical fashion to round 1. In round 3, BPR were deliberated in a teleconference and underwent voting at the cessation of the round using a 5-point Likert scale. Median scores of < 2.5, 2.5-3.75, and > 3.75 resulted in a best practice statement being rejected, reviewed in round 4, or accepted in the final BPR, respectively. In round 4, the remaining BPR were discussed and underwent voting. BPR were assigned a level of evidence and strength of recommendation based on voting results. RESULTS: Eleven PH experts agreed to participate and met expert inclusion criteria, along with 2 pharmacists from the core group, bringing the total number of expert panel members to 13. To guide safe use of PH pharmacotherapies, 26 BPR were developed, categorized into 5 practice domains, comprising the PH Care Center accreditation process, inpatient practice, formulary management, diagnostics, and ambulatory care. BPR included provisions for safe use of parenteral prostacyclin agents and healthcare practitioner education. CONCLUSION: The Delphi method was used to develop BPR to guide safe use of PH pharmacotherapies.

The Role of Double and Triple Therapy with Direct Oral Anticoagulants in Coronary Artery Disease, Peripheral Artery Disease, and Stroke.

PURPOSE: Combining antiplatelet and anticoagulant therapy is often necessary in clinical practice. However, there is limited literature on tolerability and efficacy for triple therapy with the newer direct oral anticoagulants (DOACs). The objective of this study is to characterize the discharge prescribing practice of double versus triple antithrombotic therapy with a DOAC at a large, tertiary academic medical center. METHODS: In this retrospective, cross-sectional, observational study, patients were identified if they had received any combination of a DOAC, aspirin, and a P2Y12 inhibitor during an admission at our institution from June 1, 2015, to May 31, 2016. Patients were included in the analysis if they had any indication for anticoagulation and antiplatelet therapies and were discharged from the hospital with prescriptions for a DOAC and single or dual antiplatelet agents (aspirin and/or P2Y12 inhibitor). Patients were excluded if they had an unclear indication for antiplatelet therapy. Patient characteristics and 6-month efficacy and tolerability outcomes were collected via review of the electronic medical record. FINDINGS: A total of 367 patients were included in this analysis. Most patients at our institution who required both antiplatelet and anticoagulant agents were discharged on a regimen of aspirin and a DOAC. Patients across all groups most commonly received antiplatelet therapy for coronary artery disease and acute coronary syndrome-related events, whereas they received anticoagulation for stroke prophylaxis in atrial fibrillation. Within 6 months of discharge, there were 16 bleeding-related readmissions in the DOAC-aspirin group, 1 in the DOAC-P2Y12 group, and 0 in the triple therapy group. IMPLICATIONS: This analysis found that varying combinations of antiplatelet agents and anticoagulants are used, depending on clinical indications. Further studies are needed that focus on patients with indications for dual antiplatelet therapy and anticoagulation to compare double and triple therapy strategies for efficacy and bleeding risk.

Impact of Outpatient Total Joint Replacement on Postoperative Outcomes.

Total joint arthroplasty (TJA) has demonstrated tremendous benefits to patients with osteoarthritis. Health care reform has influenced surgeons to optimize TJA care pathways as well as playing a role in the formation of outpatient TJA protocols. Understanding the outcomes of outpatient TJA is imperative to surgical predicate decision making. The aim of this review is to compare outcomes of outpatient TJA patients to standard-stay inpatients. Postoperative outcomes assessed include pain, complications, readmissions, reoperation, patient satisfaction, and cost.

Nonalcoholic Fatty Liver Disease/Nonalcoholic Steatohepatitis in Liver Transplantation.

The number of transplants caused by nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NASH) has been progressively increasing and this is expected to become the most common indication for liver transplant in the United States. Patients with NASH show many features of the metabolic syndrome and, as a result, are at higher risk for postoperative cardiovascular morbidity and mortality. Despite this, patients with NASH have long-term graft and patient survival rates comparable with other causes of chronic liver disease. Posttransplant metabolic syndrome is a common occurrence that increases the risk of steatosis in the graft liver.

Potassium Chloride Sustained Release Dosing Pathway in an Academic Medical Center.

Potassium supplementation can be administered intravenously or orally with either immediate release or sustained release formulations. Sustained release potassium chloride allows for delayed absorption and peak effects. In the inpatient setting, it is important to monitor and prevent both hypokalemia and hyperkalemia. Our tertiary-care academic hospital created a clinical pathway for sustained release potassium chloride supplementation in the inpatient population. Our clinical pathway for sustained release potassium chloride creates dosing restrictions designed to prevent hyperkalemia, while allowing exceptions for patients with high requirements.

Midwives' and patients' perspectives on disrespect and abuse during labor and delivery care in Ethiopia: a qualitative study.

BACKGROUND: It is increasingly recognized that disrespect and abuse of women during labor and delivery is a violation of a woman's rights and a deterrent to the use of life-saving, facility-based labor and delivery services. In Ethiopia, rates of skilled birth attendance are still only 28% despite a recent dramatic national scale up in the numbers of trained providers and facilities. Concerns have been raised that womens' perceptions of poor quality of care and fear of mistreatment might contribute to this low utilization. This study examines the experiences of disrespect and abuse in maternal care from the perspectives of both providers and patients. METHODS: We conducted 45 in-depth interviews at four health facilities in Debre Markos, Ethiopia with midwives, midwifery students, and women who had given birth within the past year. Students and providers also took a brief quantitative survey on patients' rights during labor and delivery and responded to clinical scenarios regarding the provision of stigmatized reproductive health services. RESULTS: We find that both health care providers and patients report frequent physical and verbal abuse as well as non-consented care during labor and delivery. Providers report that most abuse is unintended and results from weaknesses in the health system or from medical necessity. We uncovered no evidence of more systematic types of abuse involving detention of patients, bribery, abandonment or ongoing discrimination against particular ethnic groups. Although health care providers showed good basic knowledge of confidentiality, privacy, and consent, training on the principles of responsive and respectful care, and on counseling, is largely absent. Providers indicated that they would welcome related practical instruction. Patient responses suggest that women are aware that their rights are being violated and avoid facilities with reputations for poor care. CONCLUSIONS: Our results suggest that training on respectful care, offered in the professional ethics modules of the national midwifery curriculum, should be strengthened to include greater focus on counseling skills and rapport-building. Our findings also indicate that addressing structural issues around provider workload should complement all interventions to improve midwives' interpersonal interactions with women if Ethiopia is to increase provision of respectful, patient-centered maternity care.

Safety and Tolerability of Transitioning from Cangrelor to Ticagrelor in Patients Who Underwent Percutaneous Coronary Intervention.

The 3 phase 3 CHAMPION (Cangrelor vs Standard Therapy to Achieve Optimal Management of Platelet Inhibition) trials collectively demonstrated the safety of transitioning from cangrelor, a potent, parenteral rapidly-acting P2Y12 inhibitor, to clopidogrel in patients who underwent percutaneous coronary intervention (PCI). However, variation in timing of therapy, site-specific binding, and drug half-lives may theoretically complicate switching to other oral P2Y12 inhibitors. Since regulatory approval, limited data are available regarding the "real-world" safety and tolerability of transitioning to these more potent oral P2Y12 antagonists. From November 2015 to January 2017, we evaluated the clinical profiles and efficacy and safety outcomes in cangrelor-treated patients who underwent PCI transitioned to clopidogrel (n = 42) or ticagrelor (n = 82) at a large, tertiary care center. Most patients receiving cangrelor underwent PCI with a drug-eluting stent for acute coronary syndrome via a radial approach in the background of unfractionated heparin. Stent thrombosis within 48 hours was rare and occurred in 1 patient treated with ticagrelor. Global Use of Strategies to Open Occluded Coronary Arteries-defined bleeding occurred in 20% of patients switched to ticagrelor and 29% of patients switched to clopidogrel, but none were severe or life-threatening. In conclusion, rates of stent thrombosis and severe/life-threatening bleeding were low and comparable with those identified in the CHAMPION program, despite use of more potent oral P2Y12 inhibition.