Missed sepsis diagnosis can lead to increased morbidity, mortality and length of stay. Using administrative data, this retrospective study estimated the risk of potentially missed pediatric sepsis in several emergency departments. Approximately 8% of pediatric patients admitted to the hospital with sepsis experienced a treat-and-release emergency department visit within the prior 7 days. Administrative data can be helpful for hospitals in identifying cases that require detailed record review as well as evaluating the impact of sepsis alerts and bundles.

Organizational factors often play a major role in determining whether the implementation and sustainment of safety improvement initiatives are successful. Researchers studied the implementation of TeamSTEPPS across 10 rural hospitals. They found that five of the hospitals sustained facilitation activities crucial for implementation and cite senior management support, middle management support, and team continuity as organizational factors necessary for sustainment.

Critical access hospitals are located in rural areas, at least 35 miles from any other hospital. Prior studies found these hospitals may have worse outcomes for patients with acute myocardial infarction, congestive heart failure, or pneumonia, compared with other acute care hospitals. Using data from the Healthcare Cost and Utilization Project and American Hospital Association, this study examined surgical outcomes from 136 nonfederal general hospitals with fewer than 50 beds. Following adjustments for patient mix, hospital characteristics, and number of discharges, investigators found no differences in surgical patient safety indicators between critical access rural hospitals and comparably sized prospective payment hospitals. This finding demonstrates the importance of quality surgical care in rural hospitals. An AHRQ-funded toolkit provides resources for small rural hospitals interested in implementing safety measures.

Efforts to improve communication are an ongoing challenge in patient safety, particularly among providers during handoffs. Current strategies being employed include adopting structured communication tools, implementing interdisciplinary rounds, and using patient whiteboards. This study implemented bedside nursing handoffs at shift change as a patient-centered approach to reducing communication gaps. Following implementation, there were significant improvements in nursing-sensitive patient satisfaction scores compared with other nonparticipating units, though the sustainability declined after the first 6 months. The authors describe the important planning that must precede such an intervention and the barriers associated with nursing resistance to bedside shift reports. Like many quality improvement efforts, ongoing monitoring and repeat interventions are required.

Verbal orders, usually for medications, are commonly used in the inpatient setting despite being a recognized source of error. This survey of 40 hospitals found wide variation in hospital policies regarding verbal orders, with no uniform standard on which providers were allowed to give or receive verbal orders and varying approaches to documenting these orders. Although specific methods, such as read-backs, are endorsed for improving the reliability of verbal orders, few hospitals specifically mandated the use of these communication tools. A case of a misunderstood verbal order that led to a serious error is discussed in this AHRQ WebM&M commentary.

This case study describes the implementation of a health information technology–based solution to enable 24-hour remote pharmacist review of medication orders.

A computerized provider order entry system combined with decision support identified more potential adverse drug events compared to hospitals using only decision support. However, 94% of the potential adverse drug events were found to be false positives after review by a pharmacist.

Uptake of health information technology has been slow, especially in smaller hospitals and ambulatory practices. This article describes the successful implementation of an electronic medical record in a group of rural and critical access hospitals.

Computerized monitoring and alerts for adverse drug events (ADEs) are strategies adopted by hospitals to prevent medication errors. This retrospective observational study evaluated the impact of an ADE alert system in seven community hospitals; two network hospitals that did not implement the system served as controls. Investigators found that adoption of the ADE alert system led to significant decreases in pharmacy department costs, variable drug costs, and severity-adjusted mortality rates in the post-implementation period. In contrast, pharmacy department costs and drug costs increased significantly in the two network hospitals without an alert system over the same time period. The authors suggest that their findings support the potential benefits of an ADE alert system in the community hospital setting.

This study used process mapping to identify barriers to efficient medication administration and investigate the workarounds that nurses used in these situations.

This article found that the incidence of specific safety problems (as measured by the AHRQ Patient Safety Indicators) was similar for both small urban and small rural hospitals. A toolkit for implementing safety measures in rural hospitals has been published previously.

This descriptive analysis of verbal orders identifies three factors contributing to errors.

This study adds to past efforts that demonstrated a significant relationship between nurse burnout and patient safety. Although burnout was not associated with event reporting, investigators did find lower perceptions of safety in analyzing results from the AHRQ Hospital Survey on Patient Safety Culture.

… recommendations for future research. … Halbesleben JR, Wakefield DS, Wakefield BJ. Work-arounds in health care settings: …

This AHRQ-funded study discovered improved performance with selected patient safety indicators in hospitals that converted to critical access status.

The authors describe a framework to help leaders better understand, organize, and prioritize approaches to enhancing patient safety.

This study assessed a representative group of hospitals to evaluate their perception and priority of each of the National Quality Forum's (NQF) 30 "safe practices." Investigators analyzed responses from 100 hospitals and determined higher ratings for priority than for progress of the practices overall. They noted the largest discrepancy between priority and progress in creating a safety culture with the highest progress rating for increasing safe medication use. Based on evaluating individual hospital characteristics, the authors also identified 20 safe practices not associated with measures of hospital structure, capacity, or resources. These particular findings may guide other organizations trying to develop strategic safety plans with respect to NQF safety recommendations.