The transition from hospital to home is a vulnerable time as patients may have changes in medications or care needs, or difficulties accessing follow up with an outpatient provider. To reduce adverse events (AE), rehospitalizations, and emergency department visits, this hospital developed a structured discharge bundle based on the I-PASS tool used for inpatient handoffs. AE, rehospitalizations, and emergency department visits were all reduced following implementation of the I-PASS bundle.

Stigma and bias in healthcare undermine patient safety. This article discusses how stigma associated with alcohol use can impede the delivery of quality health care and contribute to poor patient outcomes. 

The Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIIPPED) program is a multicomponent intervention intended to reduce potentially inappropriate medication (PIM) prescribing among older adults who are discharged from the emergency department (ED). This cluster-randomized trial set at eight Veterans Health Administration (VA) EDs compared the impact of two approaches to the audit and feedback component of the intervention – active provider feedback using academic detailing (i.e., educational outreach visits to improve clinical decision making) versus passive provider feedback using dashboard based on the Beers criteria. Researchers found that academic detailing significantly improved PIM prescribing compared to sites using the dashboard, but noted that dashboard-based audit and feedback may be a reasonable strategy EDs with limited resources.

… family member with complex or chronic health conditions. … Morris RL, Giles S, Campbell S. Involving patients and carers …

Patient access to electronic health records can improve engagement in care. This qualitative study involving patients and staff at general practices in the United Kingdom highlighted unintended consequences of online access to health records, including challenges with patient health literacy, decreased quality of documentation, and increases in staff workload.

Patient-centered care ensures that patient values, needs and preferences are respected; however, some patient populations, such as older adults with dementia, may require assistance. This article describes iatrogenic harm resulting from well-intended assistance in residential long-term care.

The UK’s National Health Service (NHS) is increasingly using digital technology to deliver care. Researchers interviewed 19 patients and 18 general practice staff about their experiences with one of the NHS’s digital tools, online (asynchronous) consultations. Unintended consequences related to access to and efficiency of care are discussed.  

Fall prevention in healthcare settings is a patient safety priority. This systematic review found that most clinical practice guidelines provide consistent recommendations for fall prevention for older adults. Guidelines consistently recommend strategies such as risk stratification, medication review, and environment modification.

… J Am Med Inform Assoc … Clinical decision support systems are … to improved clinical care quality and research. … Morris AH, Stagg B, Lanspa M, et al. Enabling a learning healthcare system with …

Diagnostic error continues to be a source of preventable patient harm. The authors undertook a retrospective review of primary care consultations to identify incidence, origin and avoidable harm of missed diagnostic opportunities (MDO). Nearly three-quarters of MDO involved multiple process breakdowns (e.g., history taking, misinterpretation of diagnostic tests, or lack of follow up). Just over one third resulted in moderate to severe avoidable patient harm. Because the majority of MDO involve several contributing factors, interventions, including policy changes, should be multipronged.

… Jt Comm J Qual Patient Saf … This article describes the … care system's planning for the COVID-19 surge. Jt Comm J Qual Patient Saf.  Epub 2020 Oct 19. doi:  10.1016/j.jcjq.2020.09.007 …

… due to  concerns  about transmission.   … Rhee  C, Baker M, Vaidya V, et al. Incidence of nosocomial COVID-19 in …

Huddles are one technique to enhance team communication, identify safety concerns and built a culture of safety. This systematic review synthesized 24 studies examining the impact of either unit-based or hospital-wide/multiunit safety huddles. The majority of studies were uncontrolled pre-post study designs; only two studies were controlled and quantitatively measured intervention adoption and fidelity. Results for unit-based huddle programs appear positive. Given the limited number of studies evaluating hospital-wide huddle programs, the authors conclude that there is insufficient evidence to assess the benefit. Further research employing strong methodological designs is required to definitively assess the impact of huddle programs.

Resident physicians complete an annual evaluation of their training program, which includes questions on their program's culture of safety. Conducted among residency programs at a single academic medical center, this analysis found that residents in programs that emphasized safety culture had higher rates of passing their board certification exams on the first attempt.

… J Patient Saf … J Patient Saf … This study describes a multidisciplinary …

Huddles are increasingly being used to improve safety in hospitals. This commentary describes how one hospital implemented structured multidisciplinary prospective peer review of radiation oncology patient treatment plans to help prevent harm and reduce errors. The authors discuss safety culture and minimizing clinical hierarchy as drivers of success.

This qualitative study examined incident reports about surgical patients, comparing trainee reports to those submitted by attending surgeons and nurses. Trainees were more likely to enter reports anonymously and completed more elements for each report, but they also used more blame language and submitted fewer reports overall. The results suggest that encouraging trainee reporting may shed light on surgical safety.

This qualitative study employed observation, interviews, and review of documents to examine six health care organizations' efforts to improve their governing processes. Researchers found that the presence of a functioning board and the availability of adequate time and resources to improve were the key factors in enhancing organizational performance. The authors highlight the importance of focusing on these contextual factors when seeking improvement, particularly in public sector health systems.