… indicate multiple sources should be used to detect AE. … Samal L, Khasnabish S, Foskett C, et al. Comparison of a …

Medication reconciliation aims to prevent adverse events during transitions of care, but implementing effective interventions supporting medication reconciliation has proven challenging. Building upon lessons learned in the MARQUIS1 study, this pragmatic quality improvement study (MARQUIS2) implemented a refined toolkit including system-level and patient-level interventions as well as physician mentors providing remote coaching and in-person site visits. Across 17 hospital sites, the intervention was associated with a significant decrease in unintentional mediation discrepancies over time.

Using data from the Computerized Physician Order Entry (CPOE) Evaluation Tool, this study compared hospital performance against fatal orders and nuisance orders. From 2017 to 2018, overall performance increased and fatal order performance improved slightly; there was no significant change in nuisance order performance; however, these results indicate that fatal alerts are not being prioritized and that over-alerting in some cases may be contributing to alert fatigue.

A key safety feature of electronic health records is computerized provider order entry, which can reduce adverse drug events. This retrospective multisite study used simulated medication orders to determine whether electronic health record decision support detected and alerted providers about possible adverse drug events. The proportion of potential adverse drug events increased over time. Electronic health record decision support identified 54% of adverse drug events in 2009; this increased to 61.6% in 2016. There was substantial variation among hospitals using the same commercial electronic health record vendor, demonstrating the importance of local implementation decisions in medication safety. These findings emphasize the need for further efforts to enhance safety of electronic health records.

This single-site survey of resident and attending physicians across multiple specialties uncovered multiple safety vulnerabilities in the process of interhospital transfer. Investigators found that physicians and patients were both dissatisfied with timing of transfers and that critical patient records were missing upon transfer. These issues raise safety concerns for highly variable interhospital transfer practices.

… R; Galanter W; Longhurst CA; Malhotra S; Radecki RP; Samal L; Schreiber R; Shelov E; Sirajuddin AM; Sittig DF. …

Human factors engineering is being increasingly used in the design of patient safety interventions, particularly with regard to health information technology. This qualitative study examined the use of human factors and systems engineering principles within an AHRQ-funded Patient Safety Learning Laboratory that focused on implementing digital health tools to improve safety. Surveys and focus groups provided insight as to the utility of specific human factors techniques for optimizing health information technology–based interventions.

Patient engagement in safety takes many forms: patients may report unique safety incidents, encourage adherence to best medical practice, and coproduce improvement initiatives. Family-centered rounding in pediatrics invites families to express concerns, clarify information, and provide real-time input to the health care team. This pre–post study explored the safety impact of Patient and Family Centered (PFC) I-PASS rounds on 3106 admissions in pediatric units at 7 hospitals. Family-centered rounds reduced both preventable and nonpreventable adverse events. They also improved family experience without substantially lengthening rounding time. A past PSNet interview discussed the safety benefits of structured communication between health care providers and family members.

… after adoption of the new system. A previous WebM&M commentary discussed a case in which a patient experienced …

Failure to follow up abnormal test results can lead to a delayed or missed diagnosis. Using data from a single institution, researchers observed that while more than 99% of abnormal mammograms received appropriate follow-up, only 91% of abnormal Papanicolaou (Pap) smears did. They suggest that improving workflow processes and ensuring appropriate use of health information technology can help optimize test result follow-up.

Incomplete follow-up of tests pending at hospital discharge is a persistent patient safety issue. This cluster-randomized trial used medical record review to assess whether an automated notification of test results to discharging hospitalist physicians and receiving primary care physicians improved follow-up compared with usual care. The intervention was focused on actionable test results, which constituted less than 10% of all pending tests. Even with the intervention, only 60% of tests deemed actionable had any documented follow-up in the medical record, and there was no significant difference compared to usual care. The authors conclude that automated clinician notification does not constitute a sufficient intervention to optimize management of tests pending at discharge. Previous WebM&M commentaries explored problems related to tests pending at discharge and how organizations can improve follow-up of abnormal test results.

Test results pending at the time of hospital discharge can lead to a delay in diagnosis and represent a significant patient safety risk. This systematic review found that certain electronic and educational interventions may improve documentation and awareness of pending test results. The authors suggest that further research is needed to understand how these interventions affect processes and outcomes.

These paired systematic reviews examined alert fatigue in the intensive care unit. The first systematic review found several strategies to reduce alerts including prioritizing alerts, developing multipart rules instead of simple alerts, and customizing commercial platforms with end-user input. The second systematic review found that alarm best practices from high reliability industries are not adhered to in intensive care unit settings.

Establishing a strong safety culture may lead to a reduction in adverse events. Many health care institutions are focused on improving multiple aspects of culture including teamwork, communication, and patient engagement to mitigate harm. In this prospective study, researchers sought to understand the impact of a multicomponent intervention involving structured team communication as well as patient engagement tools and training on patient safety in the intensive care unit. They included 1030 admissions in the baseline period and 1075 in the intervention period. The rate of adverse events decreased by almost 30%, from 59.0 per 1000 patient days in the baseline period to 41.9 per 1000 patient days during the intervention period. Patient and care partner satisfaction improved as well. A past PSNet perspective discussed the relationship between patient engagement and patient safety.

Detecting adverse events remains a challenge across health care settings. This prospective study conducted in multiple pediatric inpatient settings used medical record review, clinician reports, and hospital incident reports to identify adverse events. Investigators compared adverse events detected with these mechanisms to adverse events identified through interviews with parents and caregivers of pediatric patients. As with previous studies, two physicians reviewed all incidents and rated the severity and preventability of all incidents. About half the incidents reported by family members were determined to be safety concerns; fewer than 10% of these incidents were felt to be preventable adverse events. Family-reported error rates were similar to error rates drawn from actively eliciting error reports from clinicians. Families were able to identify preventable adverse events that were not detected by any other method. Error rates calculated from hospital incident reports were much lower than those drawn from either clinician or family reports, consistent with prior studies. These results demonstrate that families can identify otherwise undetected adverse events and their input should be elicited in safety surveillance systems.

Test result notification is a longstanding patient safety problem. This time series analysis examined changes in documented communication between the interpreting radiologist and the treating physician for abnormal test results following implementation of an electronic alert notification system. The system allows radiologists to send alerts within their workflow for synchronous communication via pager for critical results and asynchronous communication via email for abnormal but noncritical results with alerts persisting until acknowledged by treating physicians. The authors used an automated text searching algorithm to identify radiology reports with and without documented communication and employed manual record review and adjudication to detect abnormal findings. They found that the electronic alert system led to higher levels of documented communication for abnormal findings without increasing documented communication of normal reports, allaying concerns about alert fatigue. This work demonstrates how systems thinking about provider workflow can result in technology approaches to enhance safety.

Failure to follow-up on test results in ambulatory practice is a common, serious safety concern. This study examined the use of a results manager tool by primary care physicians in Partners Healthcare in Boston. Although the vast majority of providers used the tool, many did not find that it was helpful for any specific purpose and only 64% were satisfied with the tool.

The communication of critical test results is a National Patient Safety Goal. This study describes an automated alert notification system for critical imaging results at a large academic medical center. The introduction of the system led to better closed-loop communication and appropriate documentation.

The number of handoffs a patient experiences while hospitalized has almost certainly increased at academic institutions after the implementation of duty hour restrictions, posing a significant threat to patient safety. In response, The Joint Commission required that all hospitals maintain a standardized approach to handoff communication, and in 2010 the Accreditation Council for Graduate Medical Education required that all residents receive formal handoff training. This multicenter study demonstrates that implementation of a standardized handoff bundle—which included a mnemonic ("I-PASS") for standardized oral and written signouts, formal training in handoff communication, faculty development, and efforts to ensure sustainability—was associated with a 23% relative reduction in the incidence of preventable adverse events across 9 participating pediatric residency programs. This improvement was achieved through a very high level of resident engagement in the revised handoff process, but did not negatively affect resident workflow. This rigorously designed and analyzed study establishes the I-PASS model as the gold standard for effective clinical handoffs and demonstrates the value of methodologically stringent approaches to addressing patient safety issues. A case of a delayed diagnosis due to poor handoffs is discussed in a past AHRQ WebM&M commentary.

Computerized provider order entry (CPOE) systems have been widely implemented to prevent adverse drug events due to prescribing errors. This direct observation and interview study in an outpatient pharmacy setting describes changes in practice as a result of electronic prescribing. Consistent with prior studies investigating unintended consequences of CPOE, researchers identified new errors associated with electronic prescribing, as well as potential methods to reduce adverse drug events. To improve safety, the authors recommend developing systems to track abandoned prescriptions, offering incentives for pharmacies to utilize electronic prescribing, and enhancing the interface between electronic health record and pharmacy computer systems to decrease manual entry, limit duplicated prescriptions, and expedite clarification requests. A past AHRQ WebM&M commentary describes how a nurse entered an outpatient prescription for the wrong patient and deleted it, mistakenly assuming it would cancel the order.