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June 5, 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

Pais C, Liu J, Voigt R, et al. Nat Med. 2024;30:1574-1582.
Large language models (LLMs) are artificial intelligence (AI) based tools which are increasingly used in healthcare to improve clinical decision-making and patient safety. This article describes the MEDIC (medication direction copilot) system, which uses LMMs to reduce prescribing errors by improving medication direction-related communication. The researchers tested MEDIC within an existing pharmacy workflow and found that the tool led to a 3% reduction in direction-related near miss events.
Sendak MP, Liu VX, Beecy A, et al. J Am Med Inform Assoc. 2024;31:1622–1627.
In 2022, the Food and Drug Administration (FDA) released new guidance which impacts how artificial intelligence-based clinical decision support (CDS) tools are reviewed and approved. This article explores the impact of these changes on CDS tools for sepsis care and how healthcare organizations can ensure safe, equitable use of CDS tools.

Geneva, Switzerland: World Health Organization; 2024. ISBN 9789240095458.

Comparative data can help to inform and motivate patient safety improvement efforts. This report uses the seven objectives of the Global Patient Safety Action Plan 2021–2030 to examine the impact of unsafe care worldwide and the status of plan objective implementation in the six regions of World Health Organization (WHO) member states. It shares implementation successes and suggests areas of continued focus to generate continued and innovative achievement in avoidable medical harm reduction.
Young EE, Kane J, Timmons K, et al. Diagnosis (Berl). 2024;11:186-191.
Diagnostic uncertainty can be difficult to communicate without harming patient trust. This qualitative study examined deterrents to effective sharing of clinician uncertainty with caregivers of children whose diagnosis has yet to be determined. Challenges to these conversations include lack of time, language discordance, and lack of clarity around the uncertainty concept. The diagnostic pause and visual patient education tools were suggested as strategies for improvement.
Taylor T, Columbus L, Banner H, et al. Adv Simul (Lond). 2024;9:17.
The ability to express concerns in a team is a foundational construct of a safety culture. This study used simulation to explore the dynamics of speaking up behaviors across team hierarchy during an obstetric care incident that included clinician decision errors and lapses in team respect. Participants used different strategies for raising concerns across team roles. The result found direct communication of concern disruptive to the team and patient trust, suggesting the importance of less assertive mechanisms for raising concerns in interprofessional teams.
Hesgrove B, Zebrak K, Yount N, et al. BMC Health Serv Res. 2024;24:568.
Workplace safety culture and patient safety culture differ, yet both are important to sustained improvements in safety. This study used the Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey and supplemental data to examine how both workplace and patient safety culture interrelate to reinforce organizational safety culture, such as psychological safety, to share safety concerns and leadership support for safety efforts. 
Lee S, Park J. Strat Manage J. 2024;Epub May 3.
Learning from failure is a key component of high reliability. Based on data from cardiothoracic surgeons performing coronary artery bypass graft surgeries, the authors observed a plateau at which individuals cease to learn from their own failures, underscoring the need to consider the impact of repeated failures on improving individual clinician performance.
Young EE, Kane J, Timmons K, et al. Diagnosis (Berl). 2024;11:186-191.
Diagnostic uncertainty can be difficult to communicate without harming patient trust. This qualitative study examined deterrents to effective sharing of clinician uncertainty with caregivers of children whose diagnosis has yet to be determined. Challenges to these conversations include lack of time, language discordance, and lack of clarity around the uncertainty concept. The diagnostic pause and visual patient education tools were suggested as strategies for improvement.
Pais C, Liu J, Voigt R, et al. Nat Med. 2024;30:1574-1582.
Large language models (LLMs) are artificial intelligence (AI) based tools which are increasingly used in healthcare to improve clinical decision-making and patient safety. This article describes the MEDIC (medication direction copilot) system, which uses LMMs to reduce prescribing errors by improving medication direction-related communication. The researchers tested MEDIC within an existing pharmacy workflow and found that the tool led to a 3% reduction in direction-related near miss events.
Ferguson J, Stringer G, Walshe K, et al. BMJ Qual Saf. 2024;33:354-362.
The use of temporary, or locum, clinical staff during staffing shortages may introduce process and teamwork challenges and lead to errors. This qualitative study examined a wide range of perspectives on the use of locum doctors in the United Kingdom’s National Health Service (NHS). The study identified five themes centered on familiarity, service consistency, acceptance, overuse as a protective strategy, and administrative gaps – all of which challenge patient safety. The authors call for organizations and locums to collaborate on policies to support effective integration of this workforce population.
Bunni D, Walters G, Hwang M, et al. Support Care Cancer. 2024;32:352.
Medication administration in the home can be prone to error, particularly for patients with complex medical needs. This qualitative study explored oncology patients’ willingness to report medication-related safety events after a care transition back home. Participants highlighted the importance of the patient-clinician relationship and promoting patient activation (e.g., confidence, engagement) in self-management activities. ­
Zerillo JA, Tardiff SA, Flood D, et al. Jt Comm J Qual Patient Saf. 2024;50:492-499.
Patient safety event investigations identify opportunities to prevent future events, also known as corrective actions. This analysis of 67 safety events reported at one academic medical center between 2020 and 2021 explored the relationship between the strength of proposed corrective actions and intervention completion. The research found that the majority of corrective actions were rated as weak (approximately 57%) and identified an inverse relationship between intervention strength and completion rate. 
Huang L, Riggan KA, Torbenson VE, et al. Mayo Clin Proc Innov Qual Outcomes. 2024;8:232-240.
Clinicians involved in medical mistakes benefit from assistance to psychologically recover from the experience and safely return to practice. This study explored the characteristics of the clinical learning environment to enable learners to manage the situation and their mental health post-event. Data demonstrated that blame and lack of support after patient safety incidents were still present at the institution. The authors call for targeted content to be embedded into the professional educational curriculum to help enculturate a supportive environment for second victims, and to normalize the behaviors that enable coping with the trauma of human error in medicine.
Bayramzadeh S, Ahmadpour S. HERD. 2024;17:115-128.
External sensory stimuli, such as noise and inadequate lighting, can adversely affect patient safety. This qualitative study with trauma team members explored how external sensory stimuli can impact effective team communication and contribute to fatigue and stress. Participants identify potential solutions for sensory factor issues, such as noise-level monitors in trauma rooms or the use of pencil lights or headlights for special procedures.
Dunsmore ME, Watharow A, Schneider J. J Adv Nurs. 2024;Epub Mar 22.
Patient inability to see and hear diminishes the effectiveness of their care experience, yet these conditions are not always readily evident to clinicians. This commentary highlights the need for increased attention to dual sensory impairment as a deterrent to safe, effective engagement of elderly patients in their care.
Sorich MJ, Menz BD, Hopkins AM. BMJ. 2024;384:q596.
Artificial intelligence (AI) can generate helpful information quickly, but this commentary explores its potential to misinform if the materials created are incorrect. The authors explore the risks involved in AI-created health misinformation (AI hallucinations) or malicious forms of disinformation. They suggest vetting, robust citation use, data validation, and AI training efforts to minimize distribution of potentially dangerous AI-generated content.
Sendak MP, Liu VX, Beecy A, et al. J Am Med Inform Assoc. 2024;31:1622–1627.
In 2022, the Food and Drug Administration (FDA) released new guidance which impacts how artificial intelligence-based clinical decision support (CDS) tools are reviewed and approved. This article explores the impact of these changes on CDS tools for sepsis care and how healthcare organizations can ensure safe, equitable use of CDS tools.
Kuitunen S, Airaksinen M, Holmström A-R. J Patient Saf. 2024;20:e29-e39.
Intravenous (IV) medication errors remain a common source of harm in inpatient settings. This narrative review updates previous reviews characterizing the systematic causes of, and defenses to prevent, IV medication errors. Compared to prior reviews, the researchers identified more studies using systems-based risk management approaches and a growing interest evaluating IV medication preparation systems.
No results.

Geneva, Switzerland: World Health Organization; 2024. ISBN 9789240095458.

Comparative data can help to inform and motivate patient safety improvement efforts. This report uses the seven objectives of the Global Patient Safety Action Plan 2021–2030 to examine the impact of unsafe care worldwide and the status of plan objective implementation in the six regions of World Health Organization (WHO) member states. It shares implementation successes and suggests areas of continued focus to generate continued and innovative achievement in avoidable medical harm reduction.

This Month’s WebM&Ms

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. 
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
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