Immunization Stress-Related Responses: Mitigating Patient Fears and Associated Side Effects Amidst a Global Vaccination Effort

The event of receiving a vaccine can lead to feelings of stress and anxiety for many patients and may present as adverse events. With coronavirus disease 2019 (COVID-19) mass vaccination efforts, adverse events following immunization, including immunization stress-related reactions (ISRR), have subsequently increased. Traditionally rare, but increasingly common, cluster events have also become a concern. Demonstrated in recent publications by Hause et al. concerning Janssen (Johnson & Johnson) COVID-19 vaccine clinics, these adverse events can lead to personal apprehension towards receiving vaccines, as well as public distrust towards the immunization process. To combat ISRRs, mass vaccination clinics across the United States must create administration protocols to mitigate these responses. Anticipation and swift management can play a substantial role in minimizing frequency and severity of these reactions and prevent future vaccine hesitancy.

Integration of Medication Safety Training and Development of a Culture of Safety in Pharmacy Education

Medication safety events with the potential for patient harm do occur in health care settings. Pharmacists are regularly tasked with utilizing their medication knowledge to optimize the medication use process and reduce the likelihood of error. To prepare for these responsibilities in professional practice, it is important to introduce patient safety principles during educational experiences. The Accreditation Council for Pharmacy Education (ACPE) and the American Society of Health-System Pharmacists (ASHP) have set forth accreditation standards focused on the management of medication use processes to ensure these competencies during pharmacy didactic learning and postgraduate training. The experience described here provides perspective on educational and experiential opportunities across the continuum of pharmacy education, with a focus on a relationship between a college of pharmacy and healthcare system. Various activities, including discussions, medication event reviews, audits, and continuous quality improvement efforts, have provided the experiences to achieve standards for these pharmacy learners. These activities support a culture of safety from early training.

Appropriateness of Antibiotic Prescribing in Patients Discharged From a Community Hospital Emergency Department

IMPORTANCE: Every year, thousands of emergency department (ED) visits result in patients being discharged with oral antibiotic prescriptions. Published studies that assess the appropriateness of these antibiotic regimens are limited. PURPOSE: The purpose of this study was to examine the appropriateness of antibiotic prescriptions written for patients discharged from a community hospital’s ED. ENDPOINTS: The primary objective was to determine the overall percent of appropriate antibiotic prescriptions for patients discharged from the ED. Secondary objectives included the following: identify reasons for inappropriateness categorized by antibiotic selection, dose, duration, and allergies; identify the most common antibiotics prescribed inappropriately as well as the most common disease states that led to inappropriate prescribing of antibiotics; and analyze prescribing trends based on provider type and time of day the prescription was written. STUDY DESIGN AND METHODS: Patients eligible for inclusion were adults age 18 and older who presented to the ED during four chosen weeks in 2019 and who were discharged with oral antibiotics. Extracted electronic health record data was reviewed to identify the discharge diagnosis for each patient that meets the inclusion criteria. Pertinent information gathered from the patients’ medical records along with a validated antimicrobial assessment tool were utilized to determine the level of appropriateness of the prescribed antibiotic regimens. RESULTS: A total of 76% of the prescribed antibiotics were appropriate, 16% were inappropriate, and the remaining 8% were not assessable. Duration was the most common reason for a regimen to not be optimal. The most frequently inappropriately prescribed antibiotics included cephalexin (but it is noted cephalexin was included in almost half of the antibiotic regimens in this study), clindamycin, and azithromycin. Infections that were most frequently treated inappropriately were skin and soft tissue infections, dental infections, and sinusitis. Overall, medical residents prescribed the highest percent of appropriate regimens, and the time of day that had the highest percent of appropriate prescriptions was third shift (11 p.m. to 7 a.m.). CONCLUSION AND RELEVANCE: Almost half of all the nonoptimal antibiotic regimens had an excessive duration. Targeted local education efforts and future clinical decision support can facilitate appropriate prescribing of discharge antibiotics from the ED, ultimately improving antimicrobial stewardship within the community.

Safety Considerations for the Inpatient Medication-Use Process in Pediatric and Neonatal Patients

The delivery of safe and effective healthcare to pediatric and neonatal patients presents unique challenges to the medication-use system. The diversity of patients within this population and the consequences of ontogeny on pharmacokinetics and pharmacodynamics directly impact the safe use of medications in children and increase the risk of adverse drug events.1 This review will explore the medication-use system for hospitalized children and neonates, discuss vulnerabilities within this system, and provide examples of advancements made to improve the pediatric medication-use system.

The Safety of Benzodiazepines and Opioids in the Geriatric Population: An Analysis of Patient Safety Events Reported by Hospitals and Ambulatory Surgical Facilities

Benzodiazepines may increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in patients 65 years and older. The concomitant use of benzodiazepines and opioids may also be inappropriate for older adults due to the increased risk of overdose. We searched the Pennsylvania Patient Safety Reporting System (PA-PSRS) for reports of patient safety events related to the concomitant use of benzodiazepines and opioids in older adults in order to gain a better understanding of the potential risks of using these medications in combination. We identified 80 reports in which a patient may have experienced an adverse drug reaction (ADR) to the combined use of a benzodiazepine and an opioid pain medication. Reports were reviewed to determine the ADR(s) experienced by the patient. Changes in mental status were most common, occurring in more than two-thirds of reports (68.8%; 55 of 80), followed by respiratory reactions (51.3%; 41 of 80) and cardiovascular reactions (25.0%; 20 of 80). In over two-thirds of reports (70.0%; 56 of 80), the patient received a reversal agent, either flumazenil (10.7%; 6 of 56) or naloxone (35.7%; 20 of 56), or both (53.6%; 30 of 56). The inappropriate use of benzodiazepines and opioid pain medications in combination among patients 65 years and older is a growing problem, and an increased awareness may be the first step for providers to begin addressing it.

Perioperative Delirium/Agitation Associated With the Use of Anesthetics and/or Adjunct Agents: A Study of Patient Behaviors, Injuries, and Interventions to Mitigate Risk

Anesthetics and adjunct agents have a long history of being associated with patients engaging in delirious or agitated behavior in a perioperative setting. Prior to this study, few have explored the topic with a focus on safety for both the patient and staff. We explored the Pennsylvania Patient Safety Reporting System (PA-PSRS) database for event reports to identify bouts of delirium/ agitation associated with anesthetics and/or adjunct agents that occurred during the pre-, intra-, or postoperative period. We identified 97 event reports from 63 healthcare facilities over a two-year period. Patients’ ages ranged from 1 to 91 years and 66% of the patients were reported as male. Also, 8% of the delirium/agitation occurred preoperatively, 8% intraoperatively, and 84% postoperatively. Across all three operative periods, 62% of the reports described dangerous/nonviolent behavior and 26% described dangerous/violent behavior. Additionally, 40% of the event reports described one or more patient injuries (e.g., cardiopulmonary arrest, asphyxiation, hematoma, prolapse/dehiscence, progressive ischemia) and 36% of the patients required additional healthcare services or monitoring (e.g., intra- or interfacility transfer, additional surgical procedure). Finally, 54% of the event reports described patient behavior that created an immediate and high risk of staff harm. Overall, the current study provides novel insight into how delirium/agitation has varying safety implications depending on the operative period. We encourage readers to review Table 5, which proposes a four-phase intervention package to prevent, treat, and de-escalate bouts of delirium/agitation.

2020 Pennsylvania Patient Safety Reporting: Updated Acute Care Reporting Rates

In our recent article summarizing 2020 data from acute care facilities in Pennsylvania, reporting rates and fall rates were provided for Q1 and Q2 2020 based on the latest data we had available at the time of publication. Given that 2020 was an unpredictable year in healthcare, any forecasting of rates for Q3 and Q4 2020 would have been unreliable. Therefore, this data snapshot serves to complete reporting rates for 2020 now that all hospital patient days and surgical encounters data from 2020 have been made available for rate calculations.

Correction to Taylor & Pileggi (2021)

In the article “Perioperative Delirium/Agitation Associated With the Use of Anesthetics and/or Adjunct Agents: A Study of Patient Behaviors, Injuries, and Interventions to Mitigate Risk” by Matthew A. Taylor, PhD, and William Pileggi, CRNA, MSN, MAJ, USAR/AN (Ret.) (Patient Safety, December 2021, Vol. 3, No. 4, pp 16–27. https://doi.org/10.33940/med/2021.12.2), there was an error in the Discussion section. The second sentence of paragraph two of the Discussion section should have read, “For example, during the intra- and postoperative periods the patients had dangerous behavior themes described in 75% and 74% of the event reports, respectively, compared with only 25% in the preoperative events.” The online versions of this article have been corrected.

Fixing Healthcare: How Activated Patients Can Guide Us Forward

Studies show patients who are more “activated” (i.e., invested in their care) are more likely to have better outcomes. Dr. Judith H. Hibbard, researcher and professor emerita at the University of Oregon, explains what it means to be activated—and how being so may just save your life.

Slow Down: New-Onset Atrial Fibrillation Challenges for Ambulatory Surgical Facilities

As patient safety liaisons (PSLs), we are continually educating and collaborating with our Pennsylvania healthcare facilities. We often are asked questions about reportable events under the Medical Care Availability and Reduction of Error (MCARE) Act. One of the most common examples we discuss is cancellations and transfers out of an ambulatory surgical facility (ASF). The top three reasons for cancellations include preop instructions not followed, missed medical issues identified during preop screening, and no shows. The top three reasons for transfers include cardiac arrhythmias, aspiration, and hypertension. Interestingly, between discussions with facilities and review of event reports, new-onset atrial fibrillation (AF) has come up often as a common reason for cancellations or transfers out of the ASF setting, especially in gastrointestinal (GI) procedures. In fact, as PSLs, when educating ASFs on reportable events we often give the example of placing a patient on the cardiac monitor in preop and the patient is found to be in AF. In 2009, it was estimated that 13.1% of AF cases were undiagnosed,3 which may explain why patients are presenting with new-onset AF. People with AF are at an increased risk of complications (e.g., stroke);3,4 therefore, a cancellation or transfer may be necessary depending on the patient’s condition. These events are considered reportable to the Pennsylvania Patient Safety Reporting System (PA-PSRS) under MCARE.