Adverse events and unplanned, preventable readmissions occur in approximately 20% of patients following discharge from the hospital. This randomized clinical trial compares standard care with a multi-modal discharge intervention targeting patients at highest risk of unplanned readmission. Despite the intensity of the intervention, there was no statistical difference between that intensity and the standard of care in unplanned readmission, time to readmission, or death.

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.

… Jt Comm J Qual Patient Saf … Reducing diagnostic errors is a primary patient safety concern . This qualitative study … on diagnostic errors in the acute care setting. Jt Comm J Qual Patient Saf. …

Structured tools are increasingly used to identify diagnostic errors and related harms using electronic health record data. In this study, researchers compared the performance of two validated tools (Safer Dx and the DEER taxonomy) to identify diagnostic errors among patients with preventable or non-preventable deaths. Findings indicate that diagnostic errors and diagnostic process failures contributing to death were higher in preventable deaths (56%) but were also present in non-preventable deaths (17%).

… J Hosp Med … I-PASS is a structured handoff tool to enhance communication during … I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study. J Hosp Med . Epub 2022 Nov 3. doi: 10.1002/jhm.12979 …

Post-discharge events, such as medication errors, can occur among pediatric patients discharged from inpatient settings to home. This prospective cohort, including infants discharged from one level 4 NICU between February 2017 and July 2019, identified a high risk for post-discharge adverse events, (including procedural complications and adverse drug events) and subsequent emergency department visits or hospital readmissions. Nearly half of these events were due to management, therapeutic, or diagnostic errors and could have been prevented.

… (81.3%) patients had at least one diagnostic error and a total of 113 failure points and 30 significant failure points. … Griffin JA, Carr K, Bersani K, et al. Analyzing diagnostic errors in the acute setting: a …

… Jt Comm J Qual Patient Saf … Medication reconciliation is the process of reviewing a patient’s medication list for discrepancies and safety. … at a Veterans Affairs skilled-nursing facility. Jt Comm J Qual Patient Saf. Epub 2021 Jun 11. …

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.

… J Patient Saf … Harm from opioids is a widely recognized patient safety issue, and potential harm associated with short-term use is a growing area of concern. This analysis of a previously … on hospitalized previously opioid-free surgical patients. J Patient Saf. 2021;17(2):e76-e83. …

… J Hosp Med … Based on a survey of hospital medicine groups at academic medical … in patients admitted for other reasons). … Auerbach A, O'Leary KJ, Greysen SR, et al. Hospital ward adaptation … pandemic: a national survey of academic medical centers. J Hosp Med. 2020;15(8):483-488. Epub 2020/08/18. …

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).

… J Racial Ethn Health Disparities … This study recruited … difference in incidence by race. … Costello WG, Zhang L, Schnipper J, et al. Post-discharge adverse events among …

… Am J Health Syst Pharm … This article reports mixed results of a two-year mentor-implemented feasibility study designed to … Quality Improvement Study (R-VA-MARQUIS).  Am J Health Syst Pharm . 2020;77(2):128–137. …

… J Am Med Inform Assoc … In 2014, the Agency for Healthcare … at one large tertiary care center after implementation of a PSLL intended to engage patients, families and the care … time through EHR integration.   … Businger AC, Fuller TE, Schnipper JL, Rossetti SC, Schnock KO, Rozenblum R, Dalal AK, …

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.

Champions play critical roles for implementing change in organizations. This commentary reports the results of a program to train champions of the I-PASS handoff program. The initiative used a set of tools and educational tactics to build frontline leaders' skills to mentor standardized handoffs behaviors at 32 locations. The process and tools were considered by participants as instrumental in the success of leading staff to adopt I-PASS techniques at the institutions.