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May 8, 2024 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

Hedqvist A‐T, Praetorius G, Ekstedt M, et al. J Adv Nurs. 2024;Epub Apr 20.
Transitions of care are a vulnerable time for all patients and especially older adults with complex care needs. Utilizing document review, observations, and interviews, this study describes how inconsistencies in timing and precision at the time of transition put patients at risk. Examples include early discharge from hospital due to crowding, insufficient assessment of activities of daily living, and incomplete transfer of information. A safe care transition pathway describes critical steps to ensure safe transitions.
Rydzewski NR, Dinakaran D, Zhao SG, et al. NEJM AI. 2024;1:AIoa2300151.
Large language models (LLM) are being developed to improve diagnostic accuracy. This study compared five LLMs on their accuracy of oncology diagnoses. Accuracy ranged from no better than random chance to similar to resident physicians. Notably, all models exhibited poor performance on women-predominant malignancies, suggesting a bias in training materials. This highlights the importance of partnerships between developers and medical professionals to co-develop reliable training sets.
Schiavo G, Forgerini M, Varallo FR, et al. Res Social Adm Pharm. 2024;20:576-589.
Adverse drug events (ADE) are common in older adults. This systematic review identified 12 trigger tools for detecting ADE in older adults. Trigger tools designed or adapted for the older adult population performed better than those designed for the general population. Most studies assessed performance using positive predictive value (PPV), but there was no consensus of what constitutes a good or poor PPV.
Motamedi M, Degeling C, M. Carter S. BMC Health Serv Res. 2024;24:436.
Women patients experience medical gaslighting wherein clinicians, policy makers, or the public do not believe their lived experiences. This article details more than 400 accounts submitted by women who were harmed by transvaginal mesh, and how their harm was exacerbated by dismissals by their physicians and regulatory bodies.
Goldhaber NH, Mehta S, Longhurst CA, et al. BMJ Open Quality. 2024;13:e002453.
Poor communication between team members is associated with poorer patient outcomes. To improve team communication in the operating room (OR), in one health system, personalized surgical caps with name and role were distributed to all perioperative staff. Before and after the caps were distributed, the highest mean survey score was for the item "knowing the name of an interdisciplinary team member is important for patient care." Patient outcomes (e.g., surgical site infections, return to OR) did not change during the study period, however, 72% of perioperative staff indicated they would like the hospital to continue providing named surgical caps.
Rydzewski NR, Dinakaran D, Zhao SG, et al. NEJM AI. 2024;1:AIoa2300151.
Large language models (LLM) are being developed to improve diagnostic accuracy. This study compared five LLMs on their accuracy of oncology diagnoses. Accuracy ranged from no better than random chance to similar to resident physicians. Notably, all models exhibited poor performance on women-predominant malignancies, suggesting a bias in training materials. This highlights the importance of partnerships between developers and medical professionals to co-develop reliable training sets.
Hedqvist A‐T, Praetorius G, Ekstedt M, et al. J Adv Nurs. 2024;Epub Apr 20.
Transitions of care are a vulnerable time for all patients and especially older adults with complex care needs. Utilizing document review, observations, and interviews, this study describes how inconsistencies in timing and precision at the time of transition put patients at risk. Examples include early discharge from hospital due to crowding, insufficient assessment of activities of daily living, and incomplete transfer of information. A safe care transition pathway describes critical steps to ensure safe transitions.
Mangus CW, James TG, Parker SJ, et al. Jt Comm J Qual Patient Saf. 2024;50:480-491.
The emergency department (ED) presents unique challenges in making and communicating an accurate diagnosis. This study sought perspectives of patients, nurses, and physicians about diagnostic vulnerabilities faced in the ED and suggested interventions. All three groups proposed that inter- and intrateam communication could be improved, for example with structured hand-offs between emergency medical services and the ED, and between members of the care team.
Motamedi M, Degeling C, M. Carter S. BMC Health Serv Res. 2024;24:436.
Women patients experience medical gaslighting wherein clinicians, policy makers, or the public do not believe their lived experiences. This article details more than 400 accounts submitted by women who were harmed by transvaginal mesh, and how their harm was exacerbated by dismissals by their physicians and regulatory bodies.
Hinton L, Dakin FH, Kuberska K, et al. BMJ Qual Saf. 2024;33:301-313.
Telephone and video visits are increasingly common across all clinical areas, and research into their safety is still evolving. This study with pregnant/recently pregnant women, maternity providers, and system-level stakeholders details what does and does not work well during remote prenatal visits. Participants reported increased convenience (e.g., patients not having to miss work), but also described the visits as transactional with potentially less psychological safety for sharing concerns. Additional research is required to ensure safety and equity with remote visits.
Sama SR, Quinn MM, Gore RJ, et al. J Appl Gerontol. 2024;Epub Apr 23.
Patient or client homes present unique safety challenges. This study utilized motivational interviewing by nurse managers, videos, and a safety handbook to encourage home care recipients to create safer conditions in their homes for both themselves and home care aides. The most common improvement following the nurse manager visit was improved access into the home and a reduction in trip and fall hazards.
Sova PM, Holmström A-R, Airaksinen M, et al. Eur J Hosp Pharm. 2024;31:227-233.
Medication management encompasses several stages, including ordering, preparing, dispensing, administering, and monitoring. In this study, a hospital used Healthcare Failure Mode and Effect Analysis (HFMEA) to prospectively identify risks and propose solutions when implementing a new electronic medication management system. Fifteen recommendations were made, namely ensuring correct patient identification during ordering and administration.
Newman-Toker DE, Sharfstein JM. JAMA Health Forum. 2024;5:e241339.
Artificial intelligence (AI) is seen as a primary innovation that will improve the safety and quality of health care, yet it has its detractors. This commentary explores the importance of effective policy to guide the development, training, and use of chatbots, large language models, and other elements of AI to improve its accuracy as a diagnostic tool.
Schiavo G, Forgerini M, Varallo FR, et al. Res Social Adm Pharm. 2024;20:576-589.
Adverse drug events (ADE) are common in older adults. This systematic review identified 12 trigger tools for detecting ADE in older adults. Trigger tools designed or adapted for the older adult population performed better than those designed for the general population. Most studies assessed performance using positive predictive value (PPV), but there was no consensus of what constitutes a good or poor PPV.
Ippolito M, Einav S, Giarratano A, et al. Br J Anaesth. 2024;133:111-117.
Clinician fatigue is widely viewed as a risk to patient safety. This review summarizes research of fatigue in anesthesiologists. Anesthesiologists perceive longer shift length and overnight shifts negatively impact patient safety. Even in countries that have adopted legislation to limit shift length, anesthesiologists frequently reported working longer than allowed and not getting the full rest period between shifts. A culture that fosters awareness and prevention of fatigue can improve not only patient safety, but also physician well-being.
Brook K, Agarwala AV, Tewfik GL. J Patient Saf. 2024;40:280-287.
Morbidity and mortality (M&M) conferences have long been part of medical learning. This commentary describes the historical "blame and shame" nature of early M&M conferences and outlines processes to shift them to a just culture. The ideal M&M conference should have a robust case selection process with a focus on system errors, a clear structure, and defined goals with an interdisciplinary and interprofessional audience.
Graafsma J, Murphy RM, van de Garde EMW, et al. J Am Med Inform Assoc. 2024;31:1411-1422.
Clinical decision support systems (CDSS) are widely used to prevent adverse drug events (ADE) but can generate alerts with low clinical relevance resulting in alert fatigue and high override rates. This review summarizes existing research in the use of artificial intelligence (AI) to reduce alert fatigue in CDSS. Included studies reported AI decreased inappropriate alerts. However, none of the studies reported external validation or transparency of model development.
No results.

Scott M. The Pulse. New York Public Radio; April 26, 2024.

Individuals involved in medical errors need time and support to process the incident and its consequences. This moderated podcast examines how clinicians, leaders, and patients and families respond after a patient safety event. The discussions are anchored in aptly-told stories of harm, courage, and investigation.

National Quality Forum.

Strong incident reporting systems are a foundational component for understanding preventable health care error. This initiative will work to enhance the reporting and measurement of serious reportable events (SREs) through the definition of standards to homogenize data collection across a range of established health care incident collection systems.

This Month’s WebM&Ms

WebM&M Cases
Sharmilee Vuyyuru, DO, and Nandakishor Kapa, MD |
A 57-year-old man was rushed to the Emergency Department from a nursing facility, struggling to breathe. With a history of hypertension, diabetes, and heart failure, his vital signs were concerning, showing high blood pressure, rapid heart rate, and low oxygen levels. Examinations revealed fluid buildup in his lungs and legs, indicating severe heart and kidney problems. Despite attempts to remove excess fluid with medication, dialysis became necessary. However, a complication arose during catheter insertion, requiring emergency surgery to retrieve a misplaced guidewire.
WebM&M Cases
Spotlight Case
Andrew P.J. Olson, MD, FACP, FAAP |
Five weeks after gastric bypass surgery, a woman experienced persistent nausea and vomiting, leading to dehydration and multiple outpatient treatments. Despite visiting an outpatient clinic and emergency department (ED) for ongoing symptoms and significant weight loss, the nausea and vomiting persisted. Eventually, she was admitted to the ICU with pancreatitis and dehydration. Subsequently, she exhibited neurological symptoms including difficulty walking, tingling sensations, and cognitive impairment. She was discharged with orders for total parenteral nutrition (TPN). Three days after discharge, she was readmitted for worsening confusion and profound motor weakness, which progressed to respiratory failure requiring mechanical ventilation. Laboratory tests revealed an extremely low thiamine level, and the patient was diagnosed with advanced Wernicke-Korsakoff Syndrome, exacerbated by a lack of proper nutrition, and resulting in permanent brain damage, necessitating ongoing care. The commentary discusses how biases associated with medical conditions, such as obesity and its treatment, can lead to poorer outcomes, as well as strategies to continually re-evaluate diagnostic reasoning in light of ongoing, intensive management and management reasoning
WebM&M Cases
Spotlight Case
Elizabeth Gould, NP-C, CORLN, Krystal Craddock, BSRC, RRT, RRT-ACCS, RRT-NPS, AE-C, CCM, Tyler Le Tellier, RRT, Brooks T Kuhn, MD, MAS |
A 55-year-old man with a history of osteoarthritis and supraventricular tachycardia was admitted the hospital with severe COVID-19 and required endotracheal intubation and invasive mechanical ventilation. Following transfer to a long-term care hospital (LTCH) for continued weaning from mechanical ventilation, inadequate tracheostomy management protocols were evident, with no specific instructions provided. Subsequently, the patient experienced respiratory distress and cardiac arrest due to a blocked tracheostomy tube, highlighting critical deficiencies in care and communication. The commentary summarizes the risk factors for tracheostomy complications, the importance of tracheostomy tube maintenance and monitoring, and strategies to safeguard tracheostomy tube care during transitions of care. 

This Month’s Perspectives

Katie Boston-Leary headshot
Interview
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCT |
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, CCT, is the Director of Nursing Programs at the American Nurses Association and Adjunct Professor at the University of Maryland School of Nursing and the Frances Payne Bolton School of Nursing at Case Western Reserve University. We spoke to her about patient safety amid nursing workforce challenges.
Perspective
Katie Boston-Leary, PhD, MBA, MHA, RN, NEA-BC, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD |
This piece focuses on changes in the nursing workforce over recent years, including nursing shortages. Patient safety challenges may arise from these workforce challenges, but those challenges can also be mitigated.
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