Accurate dosing and administration of liquid medications to children can be difficult for parents or caregivers. In this study, family caregivers and clinicians described their experiences at hospital discharge relating to both general and liquid-specific medication counseling. Clinicians and caregivers both stated that teach-back protocols were helpful but inconsistently used. Caregivers were not always shown how to draw up liquid into the syringes leading to them feeling uncertain about giving the correct dose. Health literacy and speaking languages other than English were also described as challenges.

COVID-19 ushered in new diagnostic challenges and changes in care practices. In this study conducted during the first wave of the pandemic, charts for hospitalized adult patients under investigation (PUI) for COVID-19 were reviewed for potential diagnostic error. Diagnostic errors were identified in 14% of cases; patients with and without diagnostic errors were statistically similar and errors were not associated with pandemic-related change practices.

Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.

I-PASS is a structured handoff tool to enhance communication during patient transfers and improve patient safety. This study found that I-PASS implementation at 32 hospitals decreased major and minor handoff-related adverse events and improved key handoff elements (e.g., frequency of handoffs with high verbal quality) across provider types and settings.

Medication reconciliations, including conducting a best possible medication history (BPMH), may occur multiple times during a hospital stay, especially at admission and discharge. By conducting BPMH analysis of 372 hospitalized older adults taking at least 5 medications at admission, researchers found that nearly 90% had at least one discrepancy. Lower age, total prehospital medication count, and admission from a non-home setting were statistically associated with more discrepancies.

… reconciliation is the process of reviewing a patient’s medication list for discrepancies and safety. Patients in …

Implementing effective interventions supporting medication reconciliation is an ongoing challenge. Using qualitative data, the authors explored how different hospitals implemented one evidence-based medication reconciliation toolkit. Thematic analyses suggest that the most commonly used implementation strategies included restructuring (e.g., altered staffing, equipment, data systems); quality management tools (e.g., audit and feedback, advisory boards); thorough planning and preparing for implementation; and education and training with stakeholders.

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.

… diagnoses in patients admitted for other reasons). … Auerbach A, O'Leary KJ, Greysen SR, et al. Hospital ward …

This mixed-methods study assessed the barriers and facilitators to hospitals’ implementation of the MARQUIS toolkit, which supports hospitals in developing medication reconciliation programs. Leadership who responded to the survey/interview expressed limited institutional budgetary and hiring support, but hospitals were able to implement and sustain the toolkit by shifting staff responsibilities, adding pharmacy staff, and using a range of implementation strategies (e.g., educational tools for staff, EHR templates).

This study examined factors facilitating or inhibiting the sustainability of rapid response teams (RRTs) by comparing two hospitals considered to have high- versus two hospitals with low sustainability RRTs. Study findings suggest that organizational factors (institutional strength and program champions) and project design/implementation factors (project effectiveness, training, funding) were critical for RRT sustainability. Individual and team characteristics should also be considered potential facilitators or inhibitors of RRT sustainability, as the study found that program champions’ actions and behaviors were more important for RRT sustainability than organizational position.

This article reports mixed results of a two-year mentor-implemented feasibility study designed to improve medication reconciliation practices in rural Veterans Affairs hospitals. The authors highlight facilitators and barriers to implementing their evidence-based intervention in smaller hospitals.

The goal of medication reconciliation is to prevent unintended medication discrepancies at times of transitions in care, which can lead to adverse events. Implementing effective medication reconciliation interventions has proven to be challenging. In this AHRQ-funded quality improvement study, five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators. The toolkit was implemented at each study site by a pharmacist and a hospitalist with support from local leadership. The intervention did not achieve overall reduction in potentially harmful medication discrepancies compared to baseline temporal trends. However, significant differences existed between the study sites, with sites that successfully implemented the recommended interventions being more likely to achieve reductions in harmful medication discrepancies. The study highlights the difficulty inherent in implementing quality improvement interventions in real-world settings. A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices.

Digital tools have the potential to improve diagnosis, patient self-care, and patient–clinician communication. This commentary argues that digital tools that alter diagnosis or treatment require examination to ensure safety. The authors provide recommendations such as involving experts in evaluating the tools, engaging information technologists, and continuous local review and assessment to identify and address risks associated with use of such tools in practice.

Patients' health literacy can have have profound safety implications. This retrospective study found that patients with low health literacy undergoing major abdominal surgery experienced a longer length of stay during the index hospitalization.

This retrospective cohort study demonstrated that a readmission risk score could prospectively identify patients at risk for readmissions for the four target conditions for nonpayment: acute myocardial infarction, chronic obstructive pulmonary disease, pneumonia, and heart failure. These results suggest that this algorithm can identify a high-risk patient group who may benefit from interventions to prevent readmission.

Hospitals with high readmission rates face reductions in Medicare reimbursements. Understanding the patient perspective at the time of readmission may better inform future readmission reduction efforts. Researchers surveyed patients readmitted to the general medicine services within 30 days of discharge across 12 hospitals on multiple aspects of self-care. Although 91% of patients reported understanding of their discharge plan, more than 52% reported difficulty with at least one aspect of self-care after discharge.

This observational study compared nurse–physician communication on two units, one in which the physicians called a stationary phone on the unit and a receptionist located the nurse and the other in which nurses carried mobile phones. The study team found no statistically significant difference in communication-related disruptions in patient care, but they did conclude that communication was more reliable when nurses carried mobile phones, as expected.

This randomized controlled trial at two academic medical centers studied the potential benefits of providing pharmacist medication reconciliation and counseling, along with individualized telephone follow-up after discharge, for adult patients hospitalized with acute coronary syndrome or acute decompensated heart failure. This extensive intervention did not reduce readmissions or emergency department visits within 30 days of discharge, though there was a small positive effect seen in patients with low health literacy.

Despite advances in handoff practices, printed signout documents remain ubiquitous in inpatient settings. This chart review study found that the accuracy of printed signout sheets decline significantly over the course of a physician shift. This work highlights the need for more real-time updated patient information than a printed page can provide.