Enhancing Patient Safety Through Cognition and Communication (M-Safety Lab)

Principal Investigator: Sanjay Saint, M.D., M.P.H., University of Michigan, Ann Arbor, MI
AHRQ Grant No.: HS24385
Project Period: 09/30/15-12/31/19
Description: The goal of this learning lab was to implement novel methods to enhance cognition and communication among care providers to reduce hospital-acquired complications. Two main projects were conducted: Project 1 focused on developing a new monitoring system for hospitalized patients, and Project 2 addressed the common but understudied area of diagnostic error.

For Project 1, the specific aims were to:

• Detect the presence and duration of vascular and urinary catheter use and report catheter presence and duration of use to clinicians to prompt timely removal of unnecessary catheters.
• Identify areas of skin at risk for developing pressure ulcers (recently renamed by expert organizations as pressure injury) from exposure to intense or prolonged pressure, moisture, friction, and shear and report areas of at-risk skin to clinicians to prompt timely delivery of risk-reducing interventions such as patient repositioning and targeted skin care.

For Project 2, the specific aims were to:

• Evaluate whether a meta-cognitive intervention using a structured checklist, a smartphone-based differential-diagnosis expander, and collective wisdom using a social media-based tool can improve diagnostic and therapeutic decision making in patients who present with shortness of breath, compared with a local "diagnostic board.".
• Examine the role of mindfulness, motivational interviewing, and architectural design in enhancing patient safety.

The M-Safety Lab created a patient safety display—a digital bedside display of catheter and wound information pulled from the electronic medical record (EMR) every 10 minutes. The display improved provider's awareness of indwelling urinary catheters, central venous catheters, and pressure injuries (formerly called "pressure ulcers"). The improvement of provider awareness of indwelling urinary catheters from the preintervention period to the intervention period was statistically significant. The improvement in provider awareness of central venous catheters was significant for intervention rooms compared with control rooms during the same timeframe.^[1-3] Although additional testing is needed, pilot testing shows it to be feasible, portable, and useful. Leaders in other units at the University of Michigan Healthcare System have expressed interest in implementing the display.

The M-Safety Lab tested and validated a bed motion device that detects 84.8 percent of patients' motions correctly. It uses a noncontact sensor system to detect and report important patient motions, such as no motion, a sign that the patient is at-risk for pressure ulcers. Other detected motions include getting out of bed, which can increase the risk of fall events, and rhythmic motions that are indicative of seizure.^[2] Compared with commercially available pressure mattresses, this device showed improved performance and was less costly. The lab filed a provisional patent application on this device.

In addition, the M-Safety Lab created and tested tools and physical spaces to improve the diagnostic process, such as a virtual pod to limit distractions, a diagnostic checklist, and a mindfulness-based approach to help physicians focus. Not all tools were used regularly by participating physicians. Researchers concluded that more work is needed to develop interventions that would be beneficial to physicians and improve diagnostic accuracy.^[2,4-6]

To date, this PSLL's work has resulted in at least 14 peer-reviewed publications, with more than 90 citations in other publications.

Publications

2020

• Quinn M, et al. Persistent barriers to timely catheter removal identified from clinical observations and interviews. Jt Comm J Qual Patient Saf. 2020;46:99-108.
• Sankaran, RR et al. A practical guide for building collaborations between clinical researchers and engineers: lessons learned from a multidisciplinary patient safety project. J Patient Saf. 2020 Jan 30;10.1097. Online ahead of print.
• Gupta A, et al. The variability in how physicians think: a casebased diagnostic simulation exercise. Diagnosis (Berl). 2020 Jul 22. Online ahead of print.

2019

• Manojlovich M, et al. Contextual barriers to communication between physicians and nurses about appropriate catheter use. Am J Crit Care. 2019;28(4):290-8.
• Quinn M, et al. Electronic health records, communication, and data sharing: challenges and opportunities for improving the diagnostic process. Diagnosis (Berl). 2019;6(3):241-8.

2018

• Chopra V, et al. Focused ethnography of diagnosis in academic medical centers. J Hosp Med. 2018;13(10):668-72.
• Chopra V, Saint S. In Reply to "Diving Into Diagnostic Uncertainty: Strategies to Mitigate Cognitive Load. In Reference to: 'Focused Ethnography of Diagnosis in Academic Medical Centers'". J Hosp Med. 2018;13(11):805.
• Gilmartin H, et al. Pilot randomised controlled trial to improve hand hygiene through mindful moments. BMJ Qual Saf. 2018;27(10):799-806.
• Gupta A, et al. Bridging the gap between systems-based and cognitive contributions to diagnostic error. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 162. 
• Gupta A, et al. Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. Diagnosis (Berl). 2018;5(3):151-6.
• Gupta A, et al. Understanding diagnostic reasoning using a case-based approach, in hospital medicine. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 93..
• Kaiser SV, et al. Limitations of using pediatric respiratory illness readmissions to compare hospital performance. J Hosp Med. 2018;13(11):737-42.

2017

• Gupta A, et al. Malpractice claims related to diagnostic errors in the hospital. BMJ Qual Saf. 2017;27(1).
• Mody L, et al. Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non-Veterans Affairs nursing homes. Infect Control Hosp Epidemiol. 2017;38(3):287-93.

2016

• Chopra V, Saint S. Harried doctors can make diagnostic errors: they need time to think. The Conversation 2016 Aug 22. https://theconversation.com/harried-doctors-can-make-diagnostic-errors-they-need-time-to-think-63173.
• CareOregon. Motivational Interviewing for Healthcare Providers..

Reference

1. Manojlovich M, et al. Contextual barriers to communication between physicians and nurses about appropriate catheter use. Am J Crit Care. 2019;28(4):290-8.
2. Saint S, et al., Final Report: Enhancing Patient Safety Through Cognition and Communication: The M-Safety Lab. Ann Arbor: University of Michigan; 2019.
3. Quinn M, et al. Electronic health records, communication, and data sharing: challenges and opportunities for improving the diagnostic process. Diagnosis (Berl). 2019;6(3):241-8.
4. Gupta A, et al. Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. Diagnosis (Berl). 2018;5(3):151-6.
5. Gupta A, et al. Bridging the gap between systems-based and cognitive contributions to diagnostic error. Abstract published at Hospital Medicine 2018; April 8-11; Orlando, Fla. Abstract 162. 
6. Gilmartin H, et al. Pilot randomised controlled trial to improve hand hygiene through mindful moments. BMJ Qual Saf. 2018;27(10):799-806.