Patients who present to the emergency department (ED) with suicidal ideation can benefit from ED-initiated interventions, but interventions can be difficult to implement and maintain. This research builds on a 2013 study, describing the quality improvement (QI) methods used to implement the Emergency Department Safety Assessment and Follow-up Evaluation 2 (ED-SAFE 2) trial. The QI approach was successful in reducing death by suicide and suicide-related acute care during the study period.

Prior research has shown that physicians with more than three paid medical malpractice claims are at increased risk of another claim in the next two years. This study assessed the risk of additional claims after just one paid malpractice claim, whether public disclosure of claims increased the risk, and whether the risk changes over time. The authors also compare actual claims rates to simulated rates if malpractice claims were “random” events unrelated to prior claims.

In this retrospective study, researchers used electronic health record and quality assurance issue (QAI) data to analyze risk factors associated with patient safety events in the emergency department (ED). Multivariable analyses showed several potential risk factors for safety events – including length of time in the ED, which increased the odds of a safety event by 4.5% for each hour spent in the ED.

… J Healthc Risk Manag … This retrospective cohort study based … practice nurses are defendants. … Myers LC, Sawicki D, Heard L, et al. A description of medical malpractice claims involving …

This article describes the implementation of the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) Secondary Screener among adult patients at eight emergency departments (EDs) in seven states from August 2010 through November 2013. Of 1,376 patients endorsing active suicidal ideation or recent suicide attempt, most were positive for at least one indicator on the ED-SAFE screener. Based on score, the research team stratified patients at mild-, moderate-, or high-risk for suicide and these strata were associated with significantly different rates of suicidal behavior and attempts after 12 months of follow-up. The researchers recommend additional validation studies and removing elements with less predictive value to increase utility of this screening tool in the ED. 

Misdiagnosis of a neurologic emergency such as stroke can lead to serious morbidity or mortality. Using a large multi-state database, this study examined the likelihood of readmission or inpatient mortality among patients who were initially discharged with nonspecific diagnoses of headache or back pain and found that 0.5% of headache and 0.2% of back pain patients experienced an inpatient death or serious neurological event after ED discharge. Extrapolated to a national level, this translates to over 55,000 patients with adverse outcomes due to a missed diagnosis for headache or back pain.

… Am J Emerg Med … This retrospective cohort study of 16,801 …

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … The Joint Commission requires hospitals … successful programs and future directions for the field. A past WebM&M commentary described the harms associated with …

… training has been used to develop skills in a safe manner in health care . This commentary draws from … use of simulation in health care. The authors recommend a research agenda to improve understanding of how simulation …

… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … Inaccurate medication reconciliation … prescribing information. In this cluster-randomized trial, a pharmacist performed medication reconciliation with access to a regional health information exchange for patients admitted …

Alarm fatigue is an increasingly recognized safety concern. This retrospective cohort study found that primary care clinicians were more likely to override alerts when there were multiple alerts per patient, but overrides were not related to overall workload or repeated exposure to the same alert. The authors recommend reducing the number of alerts per patient to address alarm fatigue.

… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … Health information technology (IT) has had a profound impact on health care. Although health IT has led … gains and improved safety , unintended consequences remain a concern. In this systematic review, researchers analyzed 69 …

Simulation training for operating room (OR) teams is an effective tool for improving teamwork and communication, but can be resource intensive and expensive. Due to these barriers, most simulation programs have only included trainees. For this study, a malpractice insurer provided the financial and administrative resources necessary to develop a standardized OR simulation training curriculum that involved active participation of attending surgeons and anesthesiologists. The group provided modest compensation for physicians' time and achieved wide participation. This teamwork curriculum covered principles of communication, assertiveness, and use of the WHO surgical safety checklist. Nearly all (93%) participants thought that the training would help them provide safer care. Dr. David Gaba discussed simulation training in a recent AHRQ WebM&M interview.

Computerized provider order entry (CPOE) reduces overall medication error rates, but this effect may depend on effective clinical decision support systems (CDSS). Whereas most previous longitudinal studies of outpatient CPOE have been performed in academic settings, this study examined community-based primary care providers, who actually write the bulk of ambulatory prescriptions. Rates of prescribing errors immediately following CPOE implementation were low, with approximately 6 errors per 100 prescriptions. These rates were sustained at 1 year following implementation. A previous AHRQ WebM&M perspective described the importance of thoughtful application of CDSS for medication prescribing.

… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … Many institutions are now moving from … advanced systems. This transition can pose safety hazards; a previous article demonstrated that replacing an older EHR with a new system resulted in a higher incidence of some types of …

In this study, better safety climates in emergency departments were associated with more intercepted near misses but not with fewer preventable adverse events.

… collaboratives have been used to successfully address a variety of patient safety problems, including medication … conducted in primary care clinics, examined the effect of a quality improvement collaborative designed to promote …

This study reports on the initial findings of a novel survey intended to evaluate safety culture in nursing homes, the Survey on Resident Safety in Nursing Homes.

Pediatric nurses reported frequently violating medication administration policies, especially in emergency situations. The impact of these protocol violations on patient safety was unclear.