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June 12, 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

Beauvais B, Pradhan R, Ramamonjiarivelo Z, et al. Risk Manag Healthc Policy. 2024;17:1361-1372.
While staffing shortages in hospitals have existed for years, they were exacerbated by the COVID-19 pandemic. Many hospitals use agency, or temporary, staff to fill these gaps. This study used national data to explore the association of use of agency staff and hospital quality measures. The results demonstrate that increased use of agency staff is associated with decreased performance in most quality measures, including Hospital Compare star rating and Hospital Value-Based Purchasing (VBP) Total Performance Score (TPS). There was no association with hospital-wide all-cause readmission rate.
Blanchard MD, Herzog SM, Kämmer JE, et al. Med Decis Making. 2024;44:451-462.
Collective intelligence in diagnosis refers to the collaboration of multiple individuals to generate a more accurate diagnosis than could be made by a single clinician. This study examined the collective intelligence of diagnostic decision making in general practice and identified the conditions associated with the greatest increase in accuracy, as well as the benefit of a computerized decision support system (CDSS). Plurality substantially outperformed average individual accuracy and the most senior group member's accuracy.
Hirani R, Noruzi K, Khuram H, et al. Life (Basel). 2024;14:557.
Artificial intelligence (AI) applications in healthcare continue to grow. This article summarizes the history and evolution of AI in healthcare and describes current applications in healthcare, such as integration with telemedicine, and advancing personalized medicine. The authors also discuss how AI being used to advance patient engagement and communication (e.g., the use of chatbots for patient engagement) and medical education, as well as ethical considerations as healthcare continues to integrate AI into practice. 
Badgery-Parker T, Li L, Fitzpatrick E, et al. J Pediatr. 2024;272:114087.
Pediatric patients are at increased risk of medication errors compared to adults, and this study sought to determine if a child's age is associated with risk of medication error. There was little association between age and prescribing errors for ages 0-3 years, then increasing until around age 10. Administration errors were steady for ages 0-8 years, and then increased with age until 18 years. 
Blanchard MD, Herzog SM, Kämmer JE, et al. Med Decis Making. 2024;44:451-462.
Collective intelligence in diagnosis refers to the collaboration of multiple individuals to generate a more accurate diagnosis than could be made by a single clinician. This study examined the collective intelligence of diagnostic decision making in general practice and identified the conditions associated with the greatest increase in accuracy, as well as the benefit of a computerized decision support system (CDSS). Plurality substantially outperformed average individual accuracy and the most senior group member's accuracy.
Gleason KT, Tran A, Fawzy A, et al. Int J Nurs Stud. 2024;155:104770.
Continuous monitoring with pulse oximeters can alert nurses to changes in patient status, but, like most electronic monitors, they can malfunction, resulting in occult hypoxemia (i.e., failure of pulse oximeter to detect clinically meaningful hypoxemia). This study assessed the potential of using frequency of nursing documentation of provider notification to identify unrecognized hypoxemia. Patients with both evident and occult hypoxemia had increased nurse documentation in the four hours before the hypoxic event. Crucially, this finding was also true in Black patients, where pulse oximeters are less likely to detect hypoxemia.
Bos K, van der Laan MJ, Groeneweg J, et al. BMJ Open Qual. 2024;13:e002592.
Strong recommendations coming out of sentinel event investigations are more likely to reduce recurrence of the event. This paper presents the recommendation improvement matrix (RIM), a method to grade the quality and strength of interventions. The RIM consists of two elements—whether the intervention occurs before or after the event and whether it eliminates or controls the hazard.
Braverman A. AORN Journal. 2024;119:421-427.
Briefings and time-outs prior to surgical procedures ensure that team members have a shared understanding of the plan and potential risks. This article describes how adding a visual component to surgical briefings, such as projecting the checklist onto a wall for all team members to see, can increase the surgical team's attention.
Øyri SF, Wiig S, Tjomsland O. BMJ Open Qual. 2024;13:e002672.
Independent investigations and regulatory authorities examine individual and system weaknesses in health care settings to prevent harm. This qualitative study involving 15 Norwegian surgeons explored perceptions around external investigations after an adverse event and impacts on transparency, reporting, and learning. Participants highlighted concerns about criminalization and scapegoating, as well as conflicting understanding or culture between medical and regulatory perspectives. 
Moyal-Smith R, Elam M, Boulanger J, et al. Jt Comm J Qual Patient Saf. 2024;Epub Apr 23.
Ambulatory safety nets (ASNs) employ a combination of approaches (e.g., patient navigators, care coordination, patient education, workflow redesigns) to enhance the safety of patients receiving outpatient care. This article describes the design and execution of a colorectal cancer (CRC) ASN to identify patients a previous abnormal CRC screen (documentation of a previous positive at-home CRC screening or overdue surveillance colonoscopy) and facilitate completion of follow-up testing. Among patients identified between October 2022 - February 2024, 40% were scheduled for a colonoscopy and 29% completed screening. 
Beauvais B, Pradhan R, Ramamonjiarivelo Z, et al. Risk Manag Healthc Policy. 2024;17:1361-1372.
While staffing shortages in hospitals have existed for years, they were exacerbated by the COVID-19 pandemic. Many hospitals use agency, or temporary, staff to fill these gaps. This study used national data to explore the association of use of agency staff and hospital quality measures. The results demonstrate that increased use of agency staff is associated with decreased performance in most quality measures, including Hospital Compare star rating and Hospital Value-Based Purchasing (VBP) Total Performance Score (TPS). There was no association with hospital-wide all-cause readmission rate.
Daneshvar N, Pandita D, Erickson S, et al. Ann Intern Med. 2024;Epub Jun 4.
The need to establish standards as artificial intelligence (AI) and machine learning are being incorporated into clinical care is paramount. This policy statement examines the use of these technologies by internists. Recommendations submitted by the American College of Physicians address transparency, decision making, privacy, equity, ethics, the patient-physician relationship, and well-being concerns. The policy concludes with a call for continued research to support the effective development and safe use of AI.
Raffel KE, Gershanik EF, Ranji SR. J Hosp Med. 2024;Epub Apr 23.
Inequities can negatively affect a wide array of health care actions, including diagnosis. This commentary tracks the components of the National Academy of Medicine (NAM) diagnostic process framework as how they can align with equity concerns to shape a method for examining inequalities within hospital-based acute care diagnostic activities. The authors discuss the role of individual hospitalists and specialty leadership to address systemic diagnostic process weaknesses that result in patient harm.
Hirani R, Noruzi K, Khuram H, et al. Life (Basel). 2024;14:557.
Artificial intelligence (AI) applications in healthcare continue to grow. This article summarizes the history and evolution of AI in healthcare and describes current applications in healthcare, such as integration with telemedicine, and advancing personalized medicine. The authors also discuss how AI being used to advance patient engagement and communication (e.g., the use of chatbots for patient engagement) and medical education, as well as ethical considerations as healthcare continues to integrate AI into practice. 
Tsang JY, Sperrin M, Blakeman T, et al. BMJ Open. 2024;14:e081698.
Polypharmacy can increase medication complexity and lead to medication errors or adverse drug events (ADEs). This scoping review examined how polypharmacy is defined, identified, and addressed across 157 articles. The authors concluded that there is no consensus definition for polypharmacy. The authors also identified considerable variability in the types of interventions used to address polypharmacy, with studies covering a wide range of aims (e.g., reducing ADEs or patient falls, or improving adherence).
Austria D, McConnell C, Pope C. J Patient Saf. 2024;20:272-278.
Inpatient nutritional errors can negatively impact a patient's recovery. This review identified fourteen studies investigating inpatient nutritional errors and subsequent patient safety investigations. Errors had various causes and multiple points of origin (e.g., foodservice system, staff). Intervention types included training, technology, checklists, and policies. The success of interventions was not reported, and the authors recommend additional research on the effectiveness of interventions.
No results.

Maternity and Newborn Safety Investigations Programme. Newcastle Upon Tyne, UK: Care Quality Commission; May 2024.

Safe maternal care is a challenge worldwide. This report analyzed 92 investigations that provided safety recommendations to improve midwifery-lead maternity care in the National Health Service. Areas of focus included workload, fetal heart monitoring during birthing, crisis preparedness, and telephone triage for pregnant persons.

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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