Peripherally inserted central catheters (PICC) represent a key source of preventable harm. Using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), the authors sought to determine if the appropriateness of PICC use decreased related medical complications including catheter occlusion, venous thromboembolism, and central line-associated bloodstream infections. Use of MAGIC in 52 Michigan hospitals increased appropriate use of PICC lines and decreased medical complications. In a 2019 PSNet Perspective, Dr. Vineet Chopra described the development and implementation of MAGIC in Michigan hospitals.  

Characterization of diagnostic error in the hospital setting has traditionally relied on data from autopsy studies, but the continuing decline in autopsy rates necessitates identification of diagnostic errors through other data sources. In this study, investigators utilized the National Practitioner Data Bank to examine the incidence and severity of inpatient diagnostic error and estimate the clinical and economic consequences of these errors. Diagnostic error accounted for 22% of paid malpractice claims over a 12-year period, resulting in $5.7 billion in payments, and the incidence of claims due to failure to diagnose increased over time. Paid claims due to diagnostic error were more likely to be for male patients older than 50, compared with other types of paid claims. Consistent with other studies, a small proportion (9%) of physicians accounted for a large proportion (51%) of payments. Although paid malpractice claims data have important limitations, this study advances our understanding of the epidemiology of diagnostic error among hospitalized patients and insights into possible preventive mechanisms.

Preventing readmissions is a cornerstone of patient safety efforts. However, one concern about nonpayment for readmissions is that many may not be preventable. To determine whether they were preventable, this observational study investigated readmissions through patient and physician surveys along with chart review. Researchers determined that only one quarter of readmissions were preventable. Factors associated with potential preventability were premature hospital discharge, insufficient communication with outpatient providers, failure to discuss care goals, and emergency department decisions to readmit a patient who did not require a second inpatient stay. These results suggest that multiple interventions will be needed to avert readmissions, and such efforts will have limited impact since most readmissions are not preventable.

Clostridium difficile infections are among the most serious health care–associated infections. In this study, most hospitals in the United States reported using C. difficile prevention measures, with the exception of antibiotic stewardship, which was in place at about half of hospitals surveyed. This finding underscores the need to focus on appropriate antibiotic use as part of patient safety efforts.

Effective teamwork plays a key role in providing safe patient care. In this study, implementation of a teamwork training intervention based on crew resource management principles improved communication between physicians and nurses on a telemetry unit.

This research letter discusses a review of cardiac arrest cases that found 25% of these cases had preventable errors, but noted poor reviewer agreement in identifying errors.

Medication errors are a leading contributor to adverse events after hospital discharge, and prior studies have demonstrated a high incidence of inadvertent medication discrepancies at the time of discharge. Pharmacist involvement in inpatient care is a proven strategy to improve safety, and a pharmacist-led medication reconciliation and education process successfully reduced medication errors and hospital readmissions in a prior study. In this trial, while the involvement of a pharmacist in medication teaching, medication reconciliation, communication of medication changes to outpatient physicians, and post-discharge telephone follow-up with patients did appear to reduce medication discrepancies, it had no impact on rates of readmissions and emergency department visits. This finding may indicate that more comprehensive discharge interventions may be necessary in order to reduce the risk of readmission.

This study analyzes findings from a 2-year program to share best practices and train hospitalists as patient safety champions in a consortium of nine Michigan hospitals.

… they are in conflict with each other. A past AHRQ WebM&M commentary discussed the unintended consequences of …