Improving diagnosis in pediatrics is an ongoing patient safety focus. This retrospective study included 129 pediatric emergency transfer cases and examined the relationship between missed opportunity for improvement in diagnosis (MOID; determined using SaferDx) and patient outcomes. Researchers found that MOID occurred in 29% of emergency transfer cases and it was associated with higher risk of mortality and longer post-transfer length of stay.

Missed recognition of early signs of clinical deterioration can result in transfer to the intensive care unit (ICU) or death. This study investigated whether critical illness events (transfer to ICU or death) impacted another patient's critical illness event in the subsequent six-hour period. Results suggest one or more critical illness events increase the odds of additional patient transfers into the ICU, but not of death. The authors present several explanations for this phenomenon.

Prediction models are increasingly used in healthcare to identify potential patient safety events. This systematic review including 25 articles identified several challenges related to electronic health record (EHR)-based prediction models for adverse drug event diagnosis or prognosis, including adherence to reporting standards, use of best practices to develop and validate prediction models, and absence of causal prediction modeling.

After-hours and weekend admissions to the hospital and intensive care units (ICU) have been linked to poor outcomes. This retrospective analysis compared outcomes among adult patients with daytime versus nighttime ICU admissions at one large Canadian medical center in between 2011 and 2015. Researchers found that overall mortality, but not ICU mortality, was higher among daytime admissions.

… patient safety learning objectives still up-to-date: a group concept mapping study. J Patient Saf. …

… J Hosp Med … I-PASS is a structured handoff tool to enhance communication during … adverse events and improved key handoff elements (e.g., frequency of handoffs with high verbal quality) across … I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study. …

… ten studies assessing symptom checkers evaluating a variety of conditions, including infectious diseases and …

According to an Agency for Healthcare Research and Quality study, an estimated 700,000 to 1 million hospitalized patients fall each year. This study assessed the impact of potentially inappropriate medications (PIM) on falls in older adults and compared the impact of three deprescribing tools on inpatient falls. PIMs identified by section K of the Screening Tool of Older Persons' Prescriptions (STOPP) had the strongest association with inpatient falls.

… data into the portal had greater odds of requesting a correction . …

Teleradiology - general radiologists who support several hospitals and read films remotely – can increase off-hours coverage but this approach can result in increased errors. This retrospective review examined errors and discrepancies between teleradiology findings and image interpretation from local facility radiologists. Most errors involved CT scans; the most common errors included missed fractures or dislocations and bleeding.

Shared mental models contribute to effective team collaboration and communication. Based on interviews and thematic analysis, the authors explored mental models between the emergency department (ED) and skilled nursing facility (SNF). The authors found that these healthcare professionals had misaligned mental models regarding communication during care transitions and healthcare setting capability, and that these misalignments led to consequences for patients, professionals, and the organization.

The authors examined contributors to error-associated deaths occurring between 1996-2004 and 2005-2014 and identified a shift from deaths occurring during the early phase of care (e.g., failed resuscitation and hemorrhage) to deaths occurring during the recovery phase (e.g., respiratory failure from aspiration). These findings demonstrate that successful implementation of system improvements can resolve process of care issues, but that ongoing evaluation is critical for continuous process improvement.

Using ethnographic methods, this study explored the impact of ‘silent report’ (computer-mediated handover) on nurses’ cognitive work and communication. The authors summarize four emerging themes, which highlight and characterize the importance of oral communication to ensure accurate and useful handovers.

Deprescribing is one strategy to reduce polypharmacy among older adults. This systematic review found that medication deprescribing interventions (particularly those involving comprehensive medication review) may provide small reductions in mortality and use of potentially inappropriate medications among community-dwelling older adults.

… chemotherapy. Most of the included oncology patients had a medication change identified after medication … (medication discontinuations). … Chun DS, Faso A, Muss HB, et al. Oncology pharmacist-led medication …

Through focus groups with patients, family caregivers and nurses, this study explored experiences with medication administration and perceived needs for assistance. Patients and caregivers were generally unaware of errors and primarily attributed administration problems to dosage form (eg, lack of confidence in using syringes). Participants identified lack of training or education about proper administration as contributing to administration errors.

Interdisciplinary teamwork is critically important in labor and delivery for anesthesiologists, obstetricians, midwives, and nurses to provide optimal care. This systematic review of interventions designed to improve teamwork found that simulation-based teamwork interventions can improve team performance and morbidity in the labor and delivery setting. 

… like Partnership for Patients have markedly reduced HACs . A PSNet interview with former AHRQ director Andrew Bindman …

… study, researchers applied machine learning techniques to a large amount of pediatric electronic health record data and …

… adapted its Comprehensive Unit-based Safety Program , a best practice toolkit incorporating teamwork, human factors … in order to improve obstetric and neonatal care safety. A recent Annual Perspective emphasizes the rising rate of …